3  &#C 
THE  GENESIS  AND  DISSOLUTION 


THETACULTY  Or  SPEECH 


A  CLINICAL  AND  PSYCHOLOGICAL 
STUDY  OF  APHASIA 


JOSEPH    COLLINS,  M.D. 

Professor  of  Diseases  of  the  Mind  and  Nervous  System  in  the  New  York 

Post-Graduate  Medical  School;  Neurologist  to  the  New  York  City 

Hospital,   to  the  St.   John's  Guild    Free    Hospital    for 

Children;  and  to  the  Post-Graduate  Hospital; 

Attending  Physician  to  the  St. 

Mark's  Hospital 


Bwaroefc  tbe  Slvarencia  prise  of  tbc  College 
of  pb\>sfcians  of  pbilafcelpbia,  1897 


Iftevv 
THE    MACMILLAN    COMPANY 

LONDON:   MACMILLAN  \-  CO..  LTD. 

1S9S 

All  right »  rexerifd 


COPYRIGHT,   1898, 

BY 

JOSEPH    COLLINS,    M.D. 


TO    MY   TEACHER 

CHARLES  L.  DANA,  M.D. 

AND    TO    MY     FRTKM) 

LIGHTNER  WITHER,  Ph.D. 

TO   WHOM    I    OWE    MY    INTELLECTUAL    AWAKEMENT 
THIS    LABOR    OF    A    YEAR'S    LEISURE    IS 

AFFECTIONATELY  DEDICATED 


PREFATORY  NOTE. 


THE  MS.  of  this  monograph  left  the  writer's  hand  in 
April,  1897.  Since  that  time  several  important  contri- 
butions have  been  made  to  our  knowledge  of  aphasia.  The 
author  regrets  that  time  and  opportunity  have  not  been 
granted  him  to  give  them  the  consideration  and  discussion 
they  merit.  Only  verbal  changes  have  been  made  in  the 
text  since  its  completion,  but  here  and  there  a  footnote 
has  been  added  to  call  attention  to  some  of  the  more  im- 
portant facts  and  striking  claims  set  forth  by  recent 
writers. 

47  WEST  THIRTY-EIGHTH  STREET,  New  York,  Christmas,  1897. 


c;- 


CONTENTS. 


CHAPTER   I. 

PAGE 

DISORDERS  OF  INTELLECTUAL  EXPRESSION,  KNOWN  AS  APHASIA,        .       i 

CHAPTER   II. 
HISTORY,  ...........     17 

CHAPTER  III. 
AN  ANALYSIS  OF  THE  GENESIS  AND  FUNCTION  OF  SPEECH,        .        .     40 

i.   General  Expressive  Reactions  ;  Mimic  Reactions.      2.  Articu- 

late Speech.      3.    Writing,     4.   The  Genesis  of  Percepts.  5.    Re- 

marks on  Visual  Sensation  ;  Acoustic  Sensation,  and  the  Mecha- 
nism of  Articulation. 

CHAPTER    IV. 
CONCEPTION  OF  APHASIA,          ........     86 

i.    Remarks  on  the  Anatomy  of  the  Brain,      z.  _&Qne.f>f  T.gflyuage. 


Site  of  Revival  of  Words  in  Silent  Thought.  3.  Evidence  in 
Favor  of  and  against  the  Existence  of  a  Special  Graphic  Motor 
Centre. 

CHAPTER    V. 
MOTOR  APHASIA,      ..........   153 

i  Motor  Aphasia;  General  Considerations.  2.  Cortical  Motor 
Aphasia  ;  Articulatory  Kinaesthetic  Aphasia.  3,  Subcortical 
Motor  Aphasia. 

CHAPTER    VI. 
SENSORY  APHASIA,   .         .         .         .         .         .         .         .         .         .  216 

i.  General  Considerations  2.  Sensory  Aphasia:  Word  Deafness, 
or  Auditor}-  Aphasia,  and  "\Vord  Blindness,  or  Visual  Aphasia. 
3.  Subcortical  Sensory  Aphasia. 


via  Contents. 

CHAPTER    VI.-  Continued. 

PAGE 
SUBCORTICAL    SENSORY    APHASIA,        .......    2g5 

CHAPTER    VII. 
TOTAL  APHASIA, 313 

CHAPTER   VIII. 
DIAGNOSIS  OK  APHASIA, 324 

CHAPTER    IX. 
ETIOLOGY,         ...........  343 

CHAPTER    X. 
MORBID  ANATOMY  OF  APHASIA,       .......  370 

CHAPTER   XI. 
REMARKS  ON  THE  TREATMENT  OF  APHASIA,  .....  396 

CHAPTER   XII. 
REMARKS  ON  THE  MEDICO-LEGAL  ASPECTS  OF  APHASIA,        .         .  407 

APPENDIX   I. 
CONDUCTION  APHASIA,     ..         \       ......  414 

APPENDIX   II 
A  CASE  OF  ARTICULATORY-KIN.KSTHKTIC  APHASIA,        .         . '       .  422 


Jlf^M  A  I 


THE  FACULTY  OF  SPEECH. 


CHAPTER    I. 

DISORDERS   OF    INTELLECTUAL    EXPRESSION,  KNOWN   AS 
APHASIA. 

Introduction. 

THE  possession  of  the  faculty  of  speech  distinguishes 
the  human  being  from  even  those  animals  which  stand 
next  to  him  in  biological  relationship.  Man  is  in  con- 
sequence inclined  to  reflect  upon  its  possession,  and  to 
speculate  concerning  its  nature  and  origin.  In  days  when 
philosophic  speculation  addressed  itself  principally  to 
a-priori  assumptions  of  the  nature  and  interrelations  of  un- 
analyzed  mental  phenomena,  the  function  of  speech,  and 
that,  too,  in  its  fully  developed  form,  was  regarded  as  an 
essential  attribute  or  inherent  faculty  of  the  human  mind, 
manifesting  itself  with  the  perfected  completeness  of  a 
Minerva  springing  from  the  brows  of  Jove.  From  the 
vagueness,  often  the  vagaries,  of  such  speculation,  there 
was  little  relief  until  attention  was  directed  to  the  de- 
velopment of  speech  in  the  infant  and  to  its  dissolution 
from  disease.  Though  of  recent  development,  labor  in 
these  two  fields  of  observation  has  extended  our  knowl- 
edge of  the  genesis  of  speech  and  thereby  given  a  basis  for- 
the  interpretation  of  its  significance.  The  genetic  method 


2  The  Faculty  of  Speech 

has  rendered  relatively  a  small  service  compared  with  the 
pathological  method.  In  this  judgment  I  am  not  unmind- 
ful of  the  value  of  many  painstaking  observations,  such  as 
those  of  Preyer  and  of  Baldwin,  that  have  aided  in  de- 
termining the  antecedent  factors  of  voluntary  articulation 
and  other  forms  of  mental  expression ;  but  it  has  been 
chiefly  from  the  study  of  those  disorders  of  speech  in- 
cluded under  the  term  aphasia,  made  by  many  students  of 
human  language,  physicians,  physiologists,  and  psycholo- 
gists, that  real  knowledge  of  the  faculty  of  speech  has 
been  acquired. 

In  introducing  the  term  aphasia,  Trousseau  first  ap- 
plied it  to  the  condition  in  which  there  was  inability  to 
express  thought  in  words ;  in  this  narrow  sense  it  was 
used  for  some  time.  When  the  part  played  by  language 
in  the  communication  of  ideas  began  to  be  studied,  it  was 
not  long  before  it  became  apparent  that  this  application 
of  the  term  was  wholly  inadequate;  an:l  that  a  word  was 
needed  not  only  to  connote  restrictedly  an  inability  to 
create  phonetic  symbols,  but  to  include  as  well  the  inability 
to  express  ideas  or  to  manifest  states  of  consciousness  by 
signs  of  all  sorts,  of  which  speech  occupied  only  the  first 
rank  in  importance.  Disturbance  of  the  power  to  express 
a  condition  of  mind  manifests  itself  in  speech,  writing, 
pantomime,  gesture,  drawing,  instrumentation,  symbols, 
coloYs,  attitudes,  etc.  To  this  end  the  term  asymbolia 
was  suggested  by  Finkenburg.  It  was  improved  upon  by 
Kussmaul,  who  substituted  the  word  asemia,  which  ad- 
mitted easy  paronymization  and  the  adjective  asemic,  and 
which  signified  literally  the  meaning  that  was  desired. 
Nevertheless,  the  term  aphasia,  sanctioned  by  time  and 


Disorders  of  Intellectual  Expression.  3 

consecrated  by  usage,  has  not  been  supplaced  by  these 
technically  better  constructed  terms.  On  the  contrary, 
aphasia  has  been  given  a  wider  significance,  a  significance 
that  attaches  to  it  to-day,  namely,  the  total  inability  or 
partial  disability  of  an  individual  to  make  outward  expres- 
sion of  thoughts,  feelings,  or  other  states  of  conscious- 
ness, whether  such  disability  result  from  interference 
with  the  formation  of  the  mental  content  or  in  the  emis- 
sion of  it. 

Aphasia  has  gone  through  many  evolutionary  stages. 
After  the  first  wave  of  its  universal  recognition  had  sub- 
sided, it  came  to  be  looked  upon  as  a  symptom  with  an 
established  seat  and  an  accompaniment  of  definite  lesions. 
As  the  literature  of  the  subject  grew  and  the  cases  with 
anomalous  symptom  complexes  became  more  numerous, 
it  was  seen  that  they  did  not  fit  in  with  the  simple  con- 
ceptions of  those  who  stood  sponsors  for  its  original 
recognition.  This,  coupled  with  the  apparent  ambition  of 
almost  every  one  who  wrote  on  the  subject  to  adopt  a  new 
nomenclature,  soon  robbed  the  symptom  of  its  attributed 
pristine  simplicity,  and  showed  it  to  be  in  reality  one  of 
the  most  complex  subjects  with  which  the  physician  and 
psychologist  had  to  deal. 

Former  and  current  nomenclature  fostered  the  obscurity 
in  which  the  subject  of  aphasia  has  been  and  is  still  en- 
shrouded. After  aphasia  had  been  recognized  as  a  symp-  • 
torn  indicative  of  localized  lesion  in  the  brain,  the  use  of 
the  words  "ataxic"  and  "amnesic"  aphasia,  the  one  to  in- 
dicate the  aphasia  of  impaired  articulation,  the  other  to 
indicate  loss  of  memory  of  the  word,  stood  obstinately  in 
the  way  of  ready  comprehension  of  the  speech  disturb- 


4  The  Faculty  of  Speech. 

ances  attending  given  cases.  Such  classification,  how- 
ever, did  not  offer  material  hindrance  to  those  who  desired 
to  study  the  subject  of  aphasia  seriously  and  scientifically, 
nor  yet  did  the  diagrammatic  portrayal  which  held  sway 
for  a  long  time. 

As  time  went  on,  students  of  the  anatomy  and  physiology 
of  the  brain  began  to  unravel  the  intricacies  of  its  archi- 
tecture and  the  mysteries  of  its  functions ;  and  it  became 
apparent  that  diagrammatic  methods,  which  necessitated 
allocating  certain  functions  to  definitely  and  sharply  local- 
ized areas  and  the  connection  of  these  areas,  the  one  with 
the  other,  by  individual  fibres,  as  well  as  the  representa- 
tion of  such  connection  in  the  incoming  and  outgoing 
pathways,  were  inimical  to  the  findings  of  science.  It 
will  be  shown  in  the  chapter  on  the  psycho-physiological 
conception  of  speech,  that  the  entire  speech  area,  i.e.,  all 
that  part  of  the  cortex  whose  functional  integrity  must  be 
preserved  for  the  production  of  speech,  whether  it  be  con- 
cerned in  the  reception  of  impressions  or  in  the  emission 
of  them,  is  practically  a  sensory  area.  Study  of  the  an- 
atomy of  the  brain,  particularly  by  the  aid  of  the  embryo- 
logical  method,  which  Flechsig  has  made  so  uniquely  his 
own,  has  thus  been  of  service  in  interpreting  the  symp- 
tomatology of  aphasia. 

A  glance  at  the  literature  register  appended  to  this 
monograph,1  and  a  perusal  of  the  chapter  devoted  to  the 
history  of  the  subject,  will  show  that  delay  in  establishing 
a  satisfactory  explanation  of  aphasia  cannot  be  attributed 

1  There  is  appended  to  the  original  manuscript  of  this  essay,  now  in  the 
archives  of  the  College  of  Physicians  of  Philadelphia,  a  bibliography  of 
aphasia  which  aims  to  indicate  the  literature  of  the  subject  up  to  January 
1st,  1897. 


Disorders  of  Intellectual  Expression.  5 

to  dearth  of  reports  of  cases.  In  fact,  the  bare  report  of  a 
simple  case  of  aphasia  is  to-day  even  considered  by  many 
writers  to  be  a  dignified  procedure ;  and,  although  it  has 
been  a  sort  of  covenant  among  medical  writers  that,  as 
soon  as  the  symptom  complex  of  a  disease  became  uni- 
versally recognized,  nothing  was  to  be  gained  by  putting 
on  record  bare  reports  of  cases  that  offered  not  the  slight- 
est difficulty  in  their  interpretation  and  that  contributed 
nothing  to  the  elucidation  of  the  problem  to  be  solved, 
recalcitrant  covenanters  are  numerous  where  .aphasia  is 
concerned.  To  show  that  this  is  not  an  exaggeration,  I 
may  refer  to  an  instance  of  recent  date  in  which  the  presi- 
dent of  a  most  learned  and  dignified  European  medical 
society  cited  a  simple  case  of  subcortical  motor  aphasia, 
which  he  referred  to  as  "quite  remarkable,"  as  a  contribu- 
tion to  "  A  Discussion  on  Aphasia"  which  had  been  opened 
by  a  savant  who  is  known  in  every  medical  community  and 
who,  in  closing  the  discussion,  disposed  of  the  simple  case 
in  a  few  simple  words. 

I  would  not  be  understood  to  say  that  the  study  of  the 
simplest  cases  of  aphasia  is  not  of  value.  It  is  of  para- 
mount importance,  and  especially  study  of  the  morbid 
anatomy.  It  is  in  such  cases  that  the  relation  between 
cause  and  effect  is  most  distinctly  traceable.  Bare  clinical 
reports  have  made  the  literature  vast  and  they  have  made 
it  a  literature  that  is  not  of  very  great  value.  Compara- 
tively few  cases  have  been  observed  in  which  careful,  ac- 
curate autopsies  were  made  and  intelligently  reported. 
This,  coupled  with  the  varying  nomenclature  that  has  been 
used  by  different  writers  and  the  different  value  put  upon 
words,  has  served  to  make  the  subject  of  aphasia  appear 


6  Tke  Faculty  of  Speech. 

much  more  intricate  than  it  really  is,  and  the  possession 
of  a  knowledge  of  it  more  difficult  than  the  phenomena 
warrant. 

That  comparatively  few  cases  carefully  observed,  prop- 
erly reported,  and  accompanied  by  details  of  post-mortem 
findings,  go  far  to  unravel  many  of  the  apparent  mys- 
teries of  aphasia  has  been  shown  by  the  contributions  of 
Wernicke,  Dejerine,  Vialet,  Redlich,  Wyllie,  Elder,  and 
of  many  others. 

Aphasia  is  a  term  used  to  indicate  any_  disturbance  or 
perversion  of  intellectual  expression.  The  significance  of 
the  term  has  expanded  from  the  time  when  its  application 
was  used  to  designate  a  defect  in  the  verbal  expression  of 
an  idea,  until  now  it  includes  all  defects  or  disorders  of 
intellectual  expression,  whether  such  disorders  be  the  re- 
sult of  disarrangement  or  destruction  of  the  receptive  or 
of  the  emissive  components  of  speech  mechanism,  or  of 
anything  which  may  be  employed  as  the  analogue  of 
speech.  Thus /a  person  who,  despite  the  integrity  of  the 
peripheral  speech  mechanism,  is  unable  to  utter  his  own 
name,  or  to  give  expression  to  thoughts  which  arise  in  the 
usual  way,  has  aphasia.  If  he  is  incapable  of  making 
known  his  thoughts  by  the  employment  of  some  equivalent 
of  spoken  words,  such  as  writing  of  any  sort  or  by  expres- 
sive mimicry  or  pantomime,  he  likewise  has  aphasia. 
Moreover,  a  person  has  aphasia  who,  with  the  extra-cere- 
bral apparatus  intact,  is  unable  to  understand  the  lan- 
guage in  whose  use  he  has  been  trained ;  does  not  even 
recognize,  although  he  hears,  the  sounds  of  the  most 
familiar  nature  and  words  to  which  he  has  for  a  lifetime 
been  accustomed,  such  as  his  own  name ;  although  he  may 


Disorders  of  Intellectual  Expression.  7 

be  able  to  read,  is  unable  to  write  voluntarily  or  from  dic- 
tation, or  to  express  his  thoughts  by  words,  by  symbols, 
or  by  pantomime. 

Yet  even  these  shortcomings  do  not  comprise  all  that 
is  meant  by  aphasia.  If  a  person  with  normal  ocular 
apparatus  looks  upon  a  printed  or  written  page,  and  the 
symbols  there  with  which  he  has  previously  been  entirely 
familiar  convey  no  meaning  to  him  in  the  form  of  approxi- 
mate thought  or  idea,  such  person  has  aphasia,  even 
though  he  may  understand  all  that  is  communicated  orally 
to  him,  and  though  he  may  himself  be  able  to  express  his 
thoughts  (incompletely  and  defectively  however)  by  spoken 
and  written  words. 

Thus  it  will  be  seen  that  aphasia,  in  the  broad  usage 
of  the  term,  may  be  the  result  of  conditions  by  which  the 
patient  is  unable  to  part  with  the  expressive  equivalent  of 
an  idea  which  has  been  properly  formed.  This  failure  is 
not  confined  to  words,  but  includes  all  modes  of  expres- 
sion. Or  it  may  be  caused  by  any  conditions  that  inter- 
fere with  the  reception  of  impulses  or  stimuli  that  enter 
into  the  genesis  of  ideas  used  in  the  construction  of  in- 
ternal or  external  language.  As  movement  in  some  form 
is  requisite  for  the  manifestation  of  any  and  all  expres- 
sions, defect  of  this  is  the  condition  to  which  the  term 
motor  aphasia  is  applied,  a  condition  which  is  equally  well 
expressed  by  the  term  aphasia  of  emission.  In  the  second 
form  of  aphasia,  the  sufferer  is  unable  to  adapt  receptive 
communications  and  make  them  fit  the  idea  represented 
by  the  verbal  symbol,  auditory  or  visual ;  that  is,  he  has 
lost  the  faculty  of  adapting  the  complement  of  the  word 
to  his  own  idea.  It  matters  not  whether  these  words  be 


8  The  Faculty  of  Speech. 

spoken  or  written,  or  communicated  by  some  equivalent, 
such  as  music  and  pantomime.  In  a  general  way,  this 
is  the  aphasia  of  reception,  or  sensory  aphasia. 

Motor  aphasia,  or  aphasia  of  emission,  which  was  de- 
scribed by  Broca  as  aphemia,  and  by  many  writers  after 
him  as  ataxic  aphasia,  may  be  divided  into  as  many  forms 
as  there  are  habitual  avenues  of  exteriorizing  thoughts. 
Ideas  are  usually  exteriorized  by  spoken  words,  by  written 
words,  by  symbols,  and  by  pantomime.  Thus,  we  have 
aphasia  of  articulation,  or  logaphasia;  and  aphasia  of 
writing,  agraphia  or  logagraphia;  asymbolia,  and  asemia. 
Aphasia  of  reception,  or  sensory  aphasia,  is  also  made  up 
of  a  number  of  constituents,  the  two  great  divisions  being 
auditory  aphasia  or  word  deafness,  and  visual  aphasia  or 
word  blindness.  Each  form  of  aphasia  admits  in  turn  of 
further  subdivision.  The  understanding  of  the  subject  of 
aphasia  depends  upon  a  comprehension  of  the  develop- 
ment of  the  powers  of  language  and  thought.  It  has 
seemed  to  me  necessary,  therefore,  to  say  something  of  the 
conditions  under  which  these  are  developed,  before  pro- 
ceeding to  the  clinical  side  of  aphasia,  although  it  would 
be  manifestly  out  of  place  in  a  monograph  of  this  kind  to 
trace  the  evolution  of  speech  in  detail  from  the  time  of 
the  child's  birth  to  the  period  when  the  speech  faculties 
have  reached  their  highest  development.  Before  proceed- 
ing to  this  psychological  consideration,  however,  it  seems 
to  me  desirable  to  present  as  succinctly  as  possible  a  con- 
sensus of  the  opinions  furnished  by  physiology,  psychology, 
pathology,  and  anatomy  as  to  the  location,  interconnection, 
and  relative  importance  of  the  different  speech  centres ;  or, 
to  be  more  explicit,  the  areas  by  virtue  of  whose  integrity 


Disorders  of  Intellectual  Expression.  9 

a  person  is  able  to  adapt  sensations  coming  through  the 
special  senses  to  the  idea  represented  by  such  sensations, 
or  to  adapt  and  produce  words  to  ideas  which  are  con- 
ceived by  him.  After  a  brief  consideration  of  the  history 
of  aphasia  I  shall  take  up  the  subject  in  the  manner  in- 
dicated. I  am  aware  that  this  mode  of  attack  may  not 
commend  itself,  at  first  sight,  to  the  physician  who  seeks 
information  of  the  clinical  phenomena  of  aphasia  alone, 
but  I  hope  that  it  will  to  him  who  would  understand  the 
genesis  of  speech,  as  well  as  the  phenomena  of  its  disso- 
lution. 

Classification  of  Aphasia. 

The  externalization  of  thought  requires  : 

I.  («)  The  production  of  movements  through  the  muscu- 
lature of  the  thorax,  the  larynx,  the  tongue,  and  the  lips,  and 
the  co-ordination  of  the  respiratory,  vocal-cord,   lingual, 
and  labial  movements,      (b}  Integrity  of  the  musculature  in- 
volved in  writing,  generally  the  muscles  of  the  right  hand, 
but  sometimes  the  muscles  of  the  left  hand,  and  very  rarely 
those  of  any  mobile  part  of  the  body,  such  as  the  foot,  and 
hence  positing    specialized  motor  areas   in   the   opposite 
cerebral    hemisphere,      (c)   Integrity  of   the    musculature 
of  the  face,  arms,  and  hands,  and  to  a  lesser  extent  of 
other  muscles  of  the  body  which  produce  pantomimic  ex- 
pression. 

II.  The  sense  organ    of    hearing,  which   is  capable  of 
being  stimulated   differentially  by  sounds  that   differ    in 
timbre,  pitch,    intensity,  and  duration,  and  possessing  a 
musculature  which  is  reflexly  stimulated  so  as  to  bring 
about  a  certain  degree  of  accommodation  or  adaptation  of 


io  Tke  Faculty  of  Speech. 

a  sense  organ  to  sounds  that  differ  in  the  above  fashion, 
and  a  conduction  tract  leading  from  the  labyrinth  to  the 
oblongata,  thence  to  the  internal  geniculate  body,  and 
to  the  cortex  in  the  anterior  region  of  the  first  temporal 
lobe. 

III.  A  sense  organ  of  vision  capable  of  differential  re- 
sponse to  form,   to   magnitude,   and   to   distance,   with  a 
musculature  possessing  a  high  degree  of  accommodative 
adaptability  to  such  different  stimuli,  and  a  conduction 
tract   which    passes   directly    to    the  external    geniculate 
body,  thence  to  the  anterior  quadrigeminal  body ;  a  larger 
bundle,    however,    passing    directly     from    the     external 
geniculate   body   into  the  pulvinar   of  the  thalamus,  and 
thence   to  adjacent    parts,   ultimately  reaching    the    cor- 
tex of  the  occipital   lobe  in  the  vicinity  of  the  calcarine 
fissure. 

IV.  Sense    organs    or    peripheral    sensory    nerves    in 
muscles,  in  joints,  and  in  adjacent  parts  which  are  cap- 
able    of    differential     stimulation     by  different     bodily 
positions   and    by  differently    executed   muscular     move- 
ments, and  afferent  tracts  leading  from  these  peripheral 
parts  to  the  cortex,  certainly  to  the  cortex  of  the  Rolan- 
dic   region,  the  so-called  somaesthetic  area,  and   possibly 
to  other  locations. 

V.  Apperception,  a  term  that  is  used  to  indicate  the 
combination  of  central  excitations  with  any  incoming  sen- 
sory stimulus  before  that  stimulus  arouses  such  excitation 
in  the  cerebral  cortex  as  to  bring  into  consciousness  a 
completed  perception. 

I  deem  it  expedient  here  to  say  a  few  words  concerning 
the  use  of  the   term   apperception,  which,  although  thor- 


Disorders  of  Intellectual  Expression.          i  i 

oughly  familiar  to  psychologists,  is  by  no  means  so  to 
physicians.  Apperception  is  a  factor  that  enters  into  all 
such  processes  as  understanding,  interpreting,  identifying. 
It  is  not  an  element  of  consciousness,  but  a  process  that 
must  intervene  between  the  presentation  of  an  object  to 
consciousness  and  the  disposition  of  such  presentation. 
It  cannot  be  maintained  that  there  are  locally  separable 
centres  of  apperception  and  of  sensation.  Apperception 
involves  past  experiences  acting  on  the  cortex,  leaving 
what  are  called  memory  traces.  Every  perception  and 
every  enunciation  of  speech  involves  the  co-ordinate  act 
of  incoming  sensory  impulses  and  of  these  cortical  mem- 
ory traces.  The  adult  consciousness  never  has  a  simple 
sensation  which  could  be  supposed  to  be  the  resultant  of 
the  activity  of  the  ganglion  cells  of  a  distinctive  sensory 
centre ;  but  incoming  impulses  may  evoke  few  or  many  of 
these  memory  traces,  in  some  cases  involving  activities 
which  represent  memory  traces  that  are  the  resultant  of 
the  actions  of  different  sense  organs.  A  study  of  aphasia 
teaches  us  that  this  central  associating  or  co-ordinating 
power  may  become  lost,  and  the  patient's  apperceptive 
powers  be  restricted,  in  some  cases  even  to  a  state  ap- 
proximating simple  sensation. 

That  an  auditory  impulse,  passing  up  the  acoustic  nerve 
through  the  oblongata,  through  the  temporal  lobe,  and 
thence  radiating  posteriorly,  inferiorly,  and  dorsally, 
awakes  in  temporal  succession  these  associated  memory 
traces,  cannot  be  doubted.  Consequently  at  one  point  we 
may  assume  that  we  have  a  simple  sensation.  That  point 
is  certainly  under  normal  conditions  not  higher  than  the 
initial  auditory  receptive  cells  in  the  middle  portion  of 


i  2  The  Faculty  of  Speech. 

the  superior  temporal  convolutions.  Whether  a  simple 
sensation  or  any  consciousness  at  all  is  produced  by  an 
activity  lower  down  cannot  be  determined. 

,A  classification  of  aphasia  is  of  much  service  in.  con- 
tributing to  a  ready  understanding  of  the  symptom  aphasia. 
I  shall  endeavor  to  give  a  simple,  natural  classification 
that  shall  be  in  harmony  with  the  interpretation  of  aphasia 
that  is  expounded  in  the  chapter  devoted  to  "  Conception 
of  Aphasia." 

Personally,  I  am  convinced  that  the  time  has  come  to 
make  radical  departure  from  the  usual  classification  of 
aphasia.  We  should  cease  the  use  of  such  misleading 
terminology  as  ataxic  aphasia,  amnesic  aphasia,  etc.,  and 
discourage  the  attitude  adopted  by  British  writers,  who 
use  the  term  aphasia  only  for  the  condition  that  most 
writers  call  motor  aphasia,  and  the  term  amnesia  for  sen- 
sory aphasia.  To  illustrate  how  confusing  and  mislead- 
ing the  nomenclature  of  the  Britishers  may  be,  I  cite  an 
instance  of  very  recent  occurrence.  A  Colonial  physician 
read  an  excellent  paper  on  "  Motor  and  Sensory  Aphasia" 
before  the  Royal  Medical  and  Chirurgical  Society.  On 
rising  to  discuss  it,  a  member  of  the  society  said  that  he 
thought  the  term  aphasia  was  hardly  justified  !  He  would 
prefer  to  call  the  condition  amnesia.  It  must  be  granted, 
I  think,  that  a  nomenclature  of  this  kind  has  not  sufficient 
in  its  favor  to  warrant  us  in  retaining  it. 

I  believe  that  aphasia  should  be  classified  as  follows : 

i.  TRUE  APHASIA. — Aphasia  of  apperception.  Due  to 
lesion  of  any  constituent  of  the  speech  region,  the  zone  of 
language.  It  might  be  subdivided  into  (a]  visual  aphasia, 
due  to  lesion  of  the  visual  areas  and  centre ;  (&)  auditory 


Disorders  of  Intellectual  Expression.         15 

Associative  or  Transcortical  Apliasia. 

I  shall  content  myself  with  mere  mention  of  this  sub- 
division, as  its  symptomatology  is  in  reality  a  part  of  sen- 
sory aphasia.  Variation  in  the  clinical  picture  is  in  ac- 
cordance with  the  location  of  the  lesion  between  speech 
areas  in  the  zone  of  language.  The  lesion  may  be : 

1.  In  the  habitual  pathway  traversed  by  impulses  going 
from  the  auditory  to  the  visual  area  (the  patient  can  hear 
a  name  but  cannot  write  it  from  hearing;  cannot  write  it 
from  dictation;  he  has  paragraphia). 

2.  It  may  be  in  the  habitual  pathway  of  impulses  going 
from  the  visual  area  to  the  auditory  area  (the  patient  can 
see  an  object,  but  he  cannot  call  up  its  name,  because  this 
requires  the  mediation  of  the  auditory  area). 

3.  A  lesion  that  interrupts  the  habitual  pathway  that 
impulses  take  when  going  from  the  auditory  to  the  seat 
of  phonetic  memories  in  Broca's  convolution  (the  patient 
can  hear,  can  interpret  from  hearing,  but  cannot  talk  cor- 
rectly:  paraphasia). 

4.  The  lesion  may  interrupt  the  pathway  taken  by  im- 
pulses going  from  the  visual  area  to  the  auditory  area  (the 
patient  is  dyslexic,  paragraphic,  and  slightly  paraphasic). 

Thus  it  will  be  seen  that  the  two  great  divisions  of 
aphasia  are  sensory  aphasia  and  motor  aphasia.  As 
I  have  said  previously,  many  British  writers,  such  as 
Bastian,  use  the  term  amnesia  synonymously  with  sen- 
sory aphasia,  and  a  greater  number  of  writers  use  the  term 
aphemia,  originally  employed  by  Broca,  as  the  specific 
term  for  the  motor  form  of  aphasia. 

Both  these  forms  of  aphasia  are  so  complex  that  it  is  nee- 


1 6  The  Faculty  of  Speech. 

essary  to  have  recourse  to  a  further  subdivision ;  the  most 
satisfactory  basis  for  which  will  have  reference  to  the  seat 
of  the  lesion  that  produces  the  speech  disturbance.  Thus 
we  have  cortical  sensory  aphasia  when  the  lesion  is  of  the 
speech  centre  itself,  and  subcortical  sensory  aphasia  when 
the  perversion  of  the  function  of  speech  is  due  to  a  lesion 
of  the  sensory  tracts  leading  to  it.  The  same  subdivision 
is  made  of  motor  aphasia,  i.e.,  cortical  motor  aphasia,  and 
subcortical  motor  aphasia.  The  designations  cortical 
sensory  and  cortical  motor  aphasia  are  often  abbreviated 
to  simply  sensory  aphasia  and  motor  aphasia  and  the  sub- 
cortical  forms  to  pure  sensory  aphasia  and  pure  motor 
aphasia  (Dejerine,  Mirallie,  et  <?/.),  thus  signifying  that 
sensory  and  motor  tracts  alone  are  involved. 


CHAPTER    II. 

* 

HISTORY. 

THE  real  history  of  aphasia  dates  from  1861.  In  that 
year  Broca  presented  an  epoch-making  communication  to 
the  Paris  Anatomical  Society,  which  seemed  to  prove  that 
the  morbid  anatomy  of  aphasia  was  a  lesion  of  the  posterior 
part  of  the  third  convolution.1  Before  that  time  much 
speculation  had  been  indulged  in  concerning  the  seat  of 
the  faculty  of  language  and  the  location  of  a  lesion  that 
would  interfere  with  its  production.  In  the  beginning  of 
the  second  half  of  the  nineteenth  century  two  patients 
were  admitted  into  the  Bicetre  Hospital  in  Paris  whose 
disorders  of  speech,  thanks  to  the  scientific  zeal  and 
clinical  insight  of  Broca,  surgeon  to  that  institution,  have 
contributed  immeasurably  to  the  understanding  of  speech 
in  both  health  and  disease. 

The  first  of  Broca's  cases  was  an  epileptic  who  had  been 
for  twenty  years  almost  completely  bereft  of  expressive 
speech,  word  production  being  limited  to  "  tan,  tan." 
The  receptive  faculties  that  contribute  to  speech  were  un- 
impaired, and  he  was  able  to  indulge  in  pantomime.  As 

1  Broca  :  "  Remarques  sur  le  siege  de  la  faculte  du  langage  articule, 
suivies  d'une  observation  d'aphemie."  Bulletin  de  la  Societe  Anatomique, 
August,  1861,  p.  330. — "  Nouvelle  observation  d'aphemie  produite  par  une 
lesion  de  la  moitie  posterieure  des  deuxieme  et  troisieme  circonvolutions 
frontales. "  Bulletin  de  la  Societe  Anatomique,  November,  1861,  p.  398. 

2 


1 8  The  Faculty  of  Speech. 

a  slowly  progressing  right  hemiplegia  developed,  intelli- 
gence waned  and  sight  became  dim.  After  death  an  ex- 
amination of  the  brain  revealed  a  widespread  softening  in 
the  left  hemisphere.  The  most  ancient  softened  area,  the 
one  to  which  the  aphasia  was  attributed  properly,  as  this 
symptom  had  preceded  the  hemiplegia  for  many  years, 
was  confined  to  the  middle  and  sylvian  side  of  the 
frontal  lobe.  The  second  case  corroborated  in  detail 
the  conclusions  drawn  from  the  first.  This  patient 
understood  all  that  was  said,  and,  although  articulatory 
production  was  reduced  to  three  or  four  words,  still  he 
used  these  intelligently  and  discreetly.  He  was  able 
to  reckon,  and  in  a  general  way  intelligence  was 
unimpaired.  Autopsy  showed  a  cavity  confined  to  the 
posterior  third  of  the  second  and  third  frontal  convolu- 
tions, a  region  which  soon  became  and  is  still  known  as 
Broca's  area.  The  report  of  these  two  cases  and  the 
discussion  to  which  it  gave  rise  attracted  widespread 
attention,  and  from  that  time  dates  the  scientific  history 
of  aphasia. 

At  first  many  of  the  most  eminent  minds  in  the  pro- 
fession refused  to  believe  that  the  emissive  speech  faculty 
was  confined  to  the  left  hemisphere ;  indeed  Broca  him- 
self looked  upon  the  lesion  in  the  left  half  of  the  brain  in 
his  two  cases  as  merely  accidental,  and  stated  his  convic- 
tion that  wider  experience  would  show  that  lesion  of  the 
corresponding  part  of  the  right  hemisphere  was  as  common 
as  of  the  left.  The  French  surgeon  was  scientific  but 
not  prophetic,  for  the  scores  of  cases  that  were  soon 
studied  and  reported  showed  that  the  lesion  was  almost 
invariably  in  the  left  hemisphere.  From  consideration  of 


History,  \  9 

the  reported  cases  and  from  wider  personal  experience, 
Broca  was  led  to  offer  in  explanation  of  this  seeming  para- 
dox of  anatomical  selection  the  hypothesis  that  the  great 
majority  of  humanity  are  right-handed  and  therefore  left- 
brained;  that  as  the  capacity  for  delicate  motor  dexterous- 
ness  is  most  developed  in  the  left  brain,  so  are  the  ex- 
quisitely co-ordinated  movements  which  subserve  speech; 
an  explanation  which  has  formed  the  basis  for  other  more 
comprehensive  hypotheses.  Indeed  Voisin1  had  made  an 
observation  which  seemed  to  demand  such  a  conclusion ; 
a  patient  with  left-sided  hemiplegia  had  no  difficulty  in 
interpreting  language  or  in  using  language.  Later  he 
developed  a  right-sided  hemiplegia  and  complete  aphasia. 
It  will  be  seen  in  further  perusal  of  this  monograph  that 
the  aphasia  which  Broca  described  and  which  he  designated 
by  the  term  aphemia,  a  word  hostilely  received  by  purists 
in  etymology,  as  literally  it  means  "  infamy,"  is  but  a 
form  or  variety  of  the  speech  disturbances  now  included 
under  that  heading. 

Broca's  communication  opened  a  new  era  in  the  under- 
standing of  speech.  It  was,  however,  no  less  epochal 
than  that  which  marks  the  direction  of  Wernicke's  master 
mind  toward  a  solution  of  the  problems  of  aphasia  in  the 
early  years  of  the  seventh  decade  of  this  century.  With- 
out taking  upon  myself  the  invidious  task  of  selecting  the 
name  of  the  one  who,  next  to  Broca,  has  made  the  most 
material  contribution  to  the  subject  of  aphasia,  it  may  be 
said  that  Broca  and  Wernicke  should  be  accorded  equal 
parental  rights  in  the  interpretation  of  the  complexity  of 

1  A.  Voisin  :  "  Observation  de  perte  de  la  parole."  Bulletin  de  1'Acade- 
mie  de  Medecine,  p.  1,241,  1862. 


2O  The  Faculty  of  Speech. 

symptoms  included  under  the  term  aphasia  to-day.  Speech 
disturbances  had  been  recognized  clinically  and  studied 
even  so  far  back  as  the  time  of  ancient  Grecian  writers, 
who  used  the  term  anandia  to  signify  loss  of  speech;  but 
the  first  records  of  serious  attempts  to  study  the  faculty 
of  speech  from  the  viewpoint  of  its  pathology  were 
made  by  Bouillaud  in  France  in  1825,  by  Jackson  in 
this  country  in  1829,  by  Dax  in  1836,  and  by  Lordat 
in  1843.  The  latter  designated  the  disturbance  of 
speech  production  by  the  word  alalia.  Many  years 
before  this  the  brilliant,  misguided  Gall  had  located 
the,  faculty  of  speech  in  the  supra-orbital  convolutions. 
Gall  died  in  1828,  and  there  can  be  no  doubt  that  his 
teachings,  which,  it  should  never  be  forgotten,  were 
based  in  part  upon  carefully  made  dissections  of  the 
brain,  had  much  to  do  with  arousing  the  interest  mani- 
fested in  these  questions  at  that  time  and  immediately 
following. 

Bouillaud  advanced  the  opinion  that  the  anterior  ex- 
tremity of  the  frontal  lobes,  despite  the  contentions  of 
Gall,  was  the  seat  of  the  faculty  of  speech.  He  was  sup- 
ported in  this  contention  by  Pinel,  Grandchamp,  and  Bel- 
homme,  the  latter  of  whom  presented  to  L' Academic 
Royale  de  Medecine  a  memoir  on  the  "  Localization  of 
Speech  in  the  Anterior  Lobes  of  the  Brain,"  in  which  by 
a  reference  to  ten  cases  he  endeavored  to  prove  that  the 
cerebral  organ  which  regulates  speech  is  seated  in  the 
anterior  lobes  of  the  brain. 

Early    in    the    century,   Lordat '    seemed    to    have    an 

1  Lordat :  Revue  Periodique  de  la  Societe  de  Paris,  December,  1820,  p. 
317. 


History.  2 1 

astonishingly  accurate  conception  of  aphasic  speech  dis- 
turbances as  they  are  understood  to-day,  for  he  distin- 
guished between  a  loss  of  memory  of  words,  which  he 
designated  "amnesic  verbale,"  and  inability  to  pronounce 
or  produce  words  which  are  the  result  of  thought,  a  condi- 
tion called  by  him  "asynergie  verbale."  He  also  recog- 
nized the  speech  defect  which  is  now  called  paraphasia, 
and  he  applied  to  it  the  term  "  paramnesie  verbale."  The 
Germans  were  in  the  field  early  and  made  several  contri- 
butions to  the  study  of  aphasia,  among  them  being  those 
of  Bergmann  in  1849,  Hasbach  in  1852,  and  Nasse  in 
1853,  but  none  of  these  was  more  than  a  report  of  cases 
analyzed  and  criticised. 

From  English  observers  no  contributions  of  signal  im- 
portance, supported  by  convincing  anatomical  proof,  were 
made  prior  to  the  publication  of  Broca's  report.  Naturally 
such  astute  clinicians  as  Prichard,  Crichton,  Winslow, 
and  Watson  did  not  allow  the  striking  and  withal  not  un- 
common symptom  to  escape  their  notice  and  remark, 
but  their  contributions  did  not  materially  advance  the 
knowledge  of  the  subject.  In  our  own  country  the  ob- 
servations of  Jackson  have  already  been  mentioned,  and 
to  them  must  be  added  those  of  Rush,1  Hun,a  Bigelow, 
and  others. 

The  history  of  aphasia,  dating  from  the  time  of  Broca's\ 
first  contributions  made  in   1861  and  in  1865,  up  to  the 
present  day,  if  written  in  detail,  now  at  the  end  of  the 
century,  would  be  more  replete  with  references  than  the 
history  of  any  other  symptom  or  disease  of  the  nervous 

1  Rush  :   "  Practice  of  Physic,"  Philadelphia,  1846. 
'*  American  Journal  of  Insanity,  1851. 


22  The  Faculty  of  Speech* 

system.  Mention  of  important  contributions  alone  covers 
many  pages,  while  to  cite  the  authors  who  simply  re- 
ported cases  corroborating  or  denying  the  anatomical 
seat  of  aphasia  as  stated  by  Broca,  and  confirmatory 
of  certain  forms  or  types  of  the  disease,  would  consume 
an  enormous  amount  of  space  and  be  without  particular 
value  except  to  the  bibliographer.  In  the  text,  I  shall 
therefore  mention  only  a  few  authors  of  the  different 
countries  who  have  made  such  contributions  to  the 
subject  as  are  destined  to  last  as  long  as  the  science  of 
medicine.  To  the  storehouses  of  information  erected  by 
these  writers  every  one  who  essays  to  write  on  aphasia 
must  go. 

The  most  important  early  American  contribution  made 
to  the  subject  of  aphasia  was  that  of  Seguin,1  who  in  1867 
published  an  elaborate  essay  detailing  a  number  of  cases 
personally  observed  and  adding  a  critical  review  of  a  large 
number  gathered  from  the  literature.  In  this  essay  he 
showed  that  out  of  a  total  of  two  hundred  and  seventy 
cases  of  hemiplegia  with  aphasia,  two  hundred  and  forty- 
three  were  paralyzed  on  the  right  side  of  the  body. 
This  corresponds  practically  to  the  ratio  of  right-handed 
to  left-handed  persons.  Several  years  later  Amidon'2 
made  an  important  contribution  to  the  pathological 
anatomy  of  sensory  aphasia,  which  included  a  critical 
analysis  of  several  typical  cases  reported  by  European 
writers. 

1  Seguin  :   "A  Statement  of  the  Aphasia  Question,  together  with  a  Report 
of  Fifty  Cases."     Quarterly  Journal  of  Psychological  Medicine,  New  York, 
1868,  vol.  ii.,  pp.  74-179. 

2  Amidon  :   "  On  the  Pathological  Anatomy  of  Sensory  Aphasia."     New 
York  Medical  Journal,  January  3151,  1885,  vol.  xli.,  pp.  113,  181. 


History.  23 

In  England  the  labors  of  Russell,1  Gairdner,2  Bastian, 3 
Broadbent,4  Ogle,5  and  Bateman6  contributed  largely  to 
our  present  knowledge ;  in  fact  the  names  of  these  phy- 
sicians are  landmarks  in  the  history  of  aphasia.  Ogle 
coined  the  word  agraphia,  although  the  condition  was  de- 
scribed first  by  Marce.  Gairdner  insisted  that  a  patient 
with  motor  aphasia  writes  at  least  as  badly  as  he  speaks, 
and  that  the  patient  wholly  unable  to  speak  is  also  inca- 
pable of  writing.  Bastian,  to  whose  interpretation  of 
clinical  phenomena  psychology  and  neurology  owe  so 
much,  was  the  first  to  recognize  the  relationship  of  defec- 
tive auditory  perception  to  speech  production.  He  intro- 
duced the  word  "  jargonaphasia"  to  indicate  the  conglom- 
eration of  syllables,  words,  and  phrases  strung  together 
without  order  or  meaning  which  is  the  striking  feature  of 
certain  forms  of  sensory  aphasia.  Broadbent  was  the  first 
to  point  out,  in  1872,  the  occurrence  of  the  condition  which 
is  now  known  as  word  blindness,  and  although  very  few  of 
the  hypotheses  advanced  by  this  writer  are  accepted  to-day, 
I  believe,  by  scarcely  an  individual  aside  from  a  few  per- 
sonal adherents,  his  writings  have  been  of  great  service  in 
furthering  an  understanding  of  some  aspects  of  aphasia. 

1  James  Russell  :  British  Medical  Journal,  1864. 

2  Gairdner  :   "  The  Function  of  Articulate  Speech,  with  Observations  on 
Aphasia,"  Glasgow,  1866. 

3  Bastian  :  St.    George's   Hospital  Reports,  vol.   ii.,  p.  95;  British  and 
Foreign    Medico-Chirurgical    Review,   vol.  xliii. ,  1869,  pp.    209,  236,  470, 
492. — "  The  Physiology  of  Thinking."     Fortnightly  Review,  1869. 

4  Broadbent  :   "  Cerebral  Mechanism  of  Thought  and  Speech. "     Medico- 
Chirurgical  Transactions,  vol.  iv. ,  1872. 

5  Ogle:  "Aphasia   and    Agraphia."      St.    George's   Hospital    Reports, 
vol.  ii.,  pp.  83-121.      Medico-Chirurgical  Transactions,  vol.  liv.,  1871. 

6  Bateman  :    "Aphasia  or  Loss  of  Speech  in  Cerebral  Disease."   Lon- 
don, 1868  ;  Revised  Edition,  London,  1890. 


24  The  Faculty  of  Speech. 

In  Germany  the  work  of  Wernicke,1  Grashey,3  Licht- 
heim, 3  and  Freud  4  has  done  much  to  extend  the  concep- 
tion of  the  term  aphasia  and  to  give  rational  explanations 
of  some  of  its  subdivisions.  Wernicke  particularly,  in 
1874,  furnished  a  basis  for  the  conception  of  sensory 
aphasia.  He  pointed  out  that  many  cases  recorded  as 
anomalous  examples  of  aphasia  could  be  explained  on  the 
ground  that  there  are  several  varieties,  and  that  the  most 
typical  aphasia  can  occur  with  lesion  of  other  parts  of  the 
brain  than  Broca's  convolution.  He  showed  clearly  that 
lesion  of  the  first  temporal  gyrus  produced  a  symptom 
complex  constituting  what  he  called  sensory  aphasia,  and 
he  portrayed  the  individual  on  whose  ears  the  words  and 
sentences  of  his  mother  language  fall  like  those  of  a  wholly 
unknown  tongue,  and  to  whose  eyes  the  letters  that  he 
formerly  read  with  an  ease  akin  to  instinct  are  as  hie- 
roglyphs. In  short,  he  interpreted  the  phenomena  of 
word  deafness  and  word  blindness  and  made  them  readily 
comprehensible  by  parallelizing  them  with  the  phenomena 

'Wernicke:  "  Der  aphasische  Symptomcomplex,"  Breslau,  1874. — 
"  Aphasie  und  Geisteskrankheit."  Deutsche  medicinische  Wochenschrift, 
p.  445,  1890. — "  Lehrbuch  der  Gehirnkrankheiten,"  Berlin,  1881. — "  Grund- 
riss  der  Psychiatric  in  klinischen  Vorlesungen,"  1894. — "  Aphasie  und  Anar- 
thrie."  Deutsche  medicinische  Wochenschrift,  p.  163,  1882. — "  Ueber  die 
motorische  Sprachbahn  und  das  Verhaltniss  der  Aphasie  mit  Anarthrie." 
Fortschritte  der  Medicin,  No.  I,  pp.  I,  405,  1884. — "  Replik  auf  Dr.  Kuss- 
maul's  Entgegnung  die  Aphasie  betreffend."  Fortschritte  der  Medicin, 
Berlin,  1883,  pp.  315,  316. — "Die  neueren  Arbeiten  iiber  Aphasie."  Fort- 
schritte der  Medicin,  ii.,  1885,  p.  24. 

Wernicke  and  Friedlander  :  Fortschritte  der  Medicin,  Berlin,  1883, 
No.  6,  p.  177. 

2  Grashey  :     "Ueber  Aphasie."     Archiv  fiir    Psychiatric  und  Xerven- 
heilkunde,  vol.  xvi.,  1885. 

3  Lichtheim  :    "Aphasia,"    Brain,    January,   1885. — "  Ueber  Aphasie." 
Deutsches  Archiv  fur  klinische  Medecin,  1884-85,  p.  204. 

4  Freud  :  "  Zur  Auffassung  der  Aphasien,"  Leipzig,  1891. 


History.  25 

of  motor  aphasia,  which  by  this  time  had  been  put  on  a 
firm  anatomical  basis.  Another  very  important  service 
which  this  writer  rendered  was  to  give  proper  application 
to  the  term  sensory  aphasia  and  to  submerge  the  term 
amnesic  aphasia,  which  for  a  time  had  found  its  way  into 
literature. 

Aside  from  Broca  and  Wernicke,  the  three  great  names 
that  stand  out  above  those  of  all  the  others  who  early 
increased  our  knowledge  of  aphasia  are  Trousseau1  in 
France,  Hughlings  Jackson3  in  England,  and  Kussmaul 3 
in  Germany,  the  latter  having  written  what  is  to-day  the 
soundest  and  fullest  treatise  on  the  subject  of  aphasia  in 
any  language. 

In  his  exhaustive  and  philosophical  consideration  of 
aphasia,  published  in  1877,  Kussmaul  introduced  the 
terms  "  word  deafness"  and  "  word  blindness"  to  indicate 
the  conditions  described  by  Wernicke,  and  although  the 
latter  and  others  hesitated  to  accept  some  of  the  conten- 

1  Trousseau  :   "  Discours  sur  1'Aphasie."     Bull.   Acad.  Med.,  February 
25th,   1861  ;    Clin.    Med.    de  1'Hotel  Dieu,  vol.  ii.,    1865,  p.    571  ;    Bull. 
Acad.  Med.,  June,  1865. — "  Lecons  cliniques  sur  1'aphasie. "    Gazette  des 
Hopitaux,  February  and  March,  1864. — "  Paralysie  progressive  de  la  langue, 
des  levres  et  du  voile  du  palais."     Gazette  des  Hopitaux,  January  and  Feb- 
ruary, 1863. 

2  Jackson  (Hughlings):    "Loss  of  Speech,   Its  Association  with  Valvu- 
lar Diseases  of  the  Heart  and  with  Hemiplegia  of  the  Right  Side."     Clini- 
cal  Lecture   and   Report    of    the    London    Hospital,    Lancet,   ii.,  1864,  p. 
604. — "On  Affection    of  Speech  from    Diseases   of   the    Brain."      Brain, 
1879-80,    t.    2,    pp.    203-323. — "On    Aphasia   with    Left    Hemiplegia." 
Lancet,   1880,  p.   637.  — "  On  Slight  and  Severe   Epileptic  Attacks  with 
Auditory  Warnings  ;  Slight  Paroxysms  with  Deafness  and  the  Special  Im- 
perception  called  Word-Blindness  ;  Spectral  (Auditory)  Words  ;   Inability 
to  Speak  and  to  Write."     Lancet,  July  28th,  1894. 

3  Kussmaul :  Article  "  Aphasia  (Disturbances  of  Speech). "    Ziemssen's 
Cyclopedia,  vol.  xii.,   Wm.  Wood  &  Co. — "  Entgegnung  die  Aphasie  be- 
treffend."     Fortschritte  der  Medicin,  Berlin,  1883,  pp.  309-313. 


26  The  Faculty  of  Speech. 

tions  of  this  writer,  particularly  those  bearing  on  the  in- 
dividuality of  word  blindness  and  its  relation  to  defective 
speech  production,  the  experience  of  innumerable  workers 
hi  the  field  of  aphasia  since  that  time  has  supported  Kuss- 
maul. 

In  1 88 1,  Exner,1  of  Vienna,  was  led,  from  an  analysis 
of  the  disturbances  of  intellectual  expression  attending 
cases  of  aphasia,  to  allocate  a  separate  area  of  the  brain  in 
which  are  stored  the  motor  memories  of  writing,  destruc- 
tion of  which  caused  agraphia.  This  centre  he  placed  at 
the  base  of  the  left  second  frontal  convolution,  and, 
although  to-day  no  one  gives  credence  to  his  method  of 
investigation,  his  conclusions  have  been  a  point  around 
which  an  active  war  has  been  waged  from  that  day  to 
this. 

Although  not  so  early  in  the  field  as  others,  the  Italians 
have  furnished  a  number  of  contributions  of  the  greatest 
value.  Of  these  mention  must  be  made  of  the  works  of 
Seppilli 2  and  of  Banti,3  both  of  a  high  standard  of  excel- 
lence. 

In  France  the  numerous  and  worthy  contributions  of 
Trousseau  were  ably  followed  up  by  those  of  Charcot,  who 
in  his  inimitable  way  suggested  an  explanation  of  aphasia 
based  apparently  on  a  psychological  analysis  of  speech, 
contrasting  the  acquisition  of  speech  with  the  phenomena 
of  dissociation  occurring  in  disease.  For  a  long  time  this 
theory  seemed  to  clarify  the  atmosphere  of  any  haziness 

1  Exner  :  "  Untersuchungen  iiber  die  Localisation  der  Functionen  in 
der  Grosshirnrinde  des  Menschen,"  Wien,  1881. 

9  Seppilli :  "  La  sordita  verbale  od  afasia  sensoriale."  Riv.  Sperim.  di 
Frenatr. ,  Reggio-Emilia,  1884,  pp.  94-95. 

3  Banti  :  "  Afasia  e  sue  forme."     Sperimentale,  Firenze,  1886. 


History.  2  7 

surrounding  the  interpretation  of  aphasia,  while  at  the 
same  time  it  furthered  the  claim  of  aphasia  to  accurate 
anatomical  localization.  The  contributions  of  Charcot ' 
had  a  capable,  lucid  exponent  and  commentator  in  his 
pupil,  Bernard.2 

It  is  the  first  duty  of  the  historian  to  be  truthful  and 
exact  in  the  statement  of  facts,  and  that  he  may  be  worthy 
of  his  task  candor  compels  the  historian  of  aphasia  to  state 
without  equivocation  that  Charcot  did  more  to  prevent  the 
true  interpretation  of  aphasia  as  it  is  understood  to-day 
than  did  any  other  writer  who  essayed  to  illumine  the  sub- 
ject. The  scientific  position  of  this  deservedly  honored 
and  renowned  physician  was  such  an  exalted  one  and  his 
utterances  were  so  generally  considered  ex  cathedra,  not 
alone  by  his  disciples  but  by  his  contemporaries,  that 
statements  from  his  pen  and  from  his  lips  were  accepted 
as  truth  before  they  had  received  the  corroboration  and 
substantiation  of  ethers,  as  the  true  scientific  spirit  de- 
mands. Far  be  it  from  me  to  detract  from  the  claims  to 
immortality  of  one  of  the  greatest  clinicians  of  the  nine- 

1  Charcot  :  "Cecite  verbale.  Lejons  sur  les  Maladies  du  Systeme 
Nerveux,"  t.  iii.,  1887,  p.  152.  —  "Observation  d'hemiplegie  droite  avec 
aphemie  et  avec  integrite  des  lobes  anterieurs  et  des  circon volutions  fron- 
tales."  Gaz.  Hebd.,  17  Juillet,  1863. — "Des  varietes  de  1'aphasie. 
Cecite  verbale."  Progres  Medical,  1883,  pp.  23,  27,  441,  521,  859. — "  Des 
varietes  de  1'aphasie.  Aphasie  motrice."  Journal  de  la  Sante  Publique, 
1883. — "  Cas  rare  de  cecite  verbale  pris  a  la  clinique  de  Charcot."  Wiener 
medizinische  Presse,  1883,  p.  834. — "Cecite  verbale."  Gazette  Medicale, 
Paris,  21  Juillet,  1883,  No.  29,  p.  339. — "  De  Taphasie."  Progres  Medi- 
cal, 4  Fevrier,  1888,  p.  81. — "  Le5ons  sur  les  localisations  dans  les  maladies 
du  cerveau  recueillis  par  Bourneville. "  Progres  Medical,  1876. 

Charcot  and  Dutil  :  "  Agraphie  motrice  suivie  d'autopsie."  Societe 
de  Biologic,  Juillet,  1893,  p.  129. 

*  Bernard  •.  ' '  De  1'aphasie  et  ses  diverses  formes. ' '  These  Doctoral, 
Paris,  1885. 


28  The  Facility  of  SpeccJi. 

teenth  century,  but  his  excursion  afield  into  the  subject  of 
aphasia  has  been  a  perpetual  obstacle  to  the  dissemination 
of  the  view  of  aphasia  that  passes  muster  to-day,  and  that 
has  been  endeavoring  to  get  a  foothold  since  Wernicke 
and  Bastian  first  began  their  interpretations  of  aphasic 
speech  disturbances. 

Charcot  framed  a  hypothesis  for  the  explanation  of 
speech,  using  the  word  bell,  the  object  bell,  the  sound 
bell,  the  touch  bell,  to  illustrate  the  various  avenues  by 
which  sensory  impressions  arise  in  the  consciousness 
and  to  show  that  the  memories  of  such  impressions  were 
stored  up  in  individual  centres.  The  speech  centres  he 
taught  were  in  pairs,  two  for  reception  of  information, 
the  auditory  centre  and  the  visual  centre,  and  two  for 
emission  of  impulses  representing  ideas,  the  articulate 
speech  centre  and  the  graphic-motor  centre.  These 
centres  Charcot  asserted,  with  great  assiduity  and  aplomb, 
were  possessed  of  striking  functional  autonomy  which 
they  had  phylogenetically  and  as  the  result  of  education. 
A  person  inherited,  or  was  born  with,  a  tendency  to  form 
concepts  mainly  by  arousing  them  through  the  visual,  the 
auditory,  or  the  articulatory  images,  and  was  destined 
therefore  to  be  in  thought  and  speech  a  visuel,  an  auditif, 
a  motenr,  and  this  predisposition  was  greatly  advanced  by 
education.  Charcot  adopted  early  the  conclusions  of 
Exner  concerning  the  existence  of  a  separate  graphic-mo- 
tor centre,  although  the  evidence  which  the  latter  adduced 
in  support  of  his  claims  was  about  as  unscientific  as 
anything  could  be.  Nevertheless  Charcot  immediately 
proceeded  to  speak  of  the  graphic-motor  centre  as  if  its 
existence  and  individuality  were  beyond  a  doubt. 


History.  29 

The  interdependence  of  the  four  centres,  and  the  neces- 
sity for  their  harmonious  co-operation,  in  order  that  intel- 
lectual expression  be  complete,  was  recognized,  but  the 
autonomy  of  each  centre  was  contended  for  unswervingly. 
Charcot  claimed  that  from  the  standpoint  of  development 
the  centres  were  independent  and  separate,  and  that  meth- 
ods of  education  as  well  as  natural  proclivities  tended  to 
the  development  of  one  of  the  centres  out  of  proportion 
to  the  others.  In  this  way,  those  who  receive  the 
wealth  of  their  sensory  impressions  through  the  hearing 
apparatus,  are  preponderatingly  auditives ;  those  whose 
education  is  most  aided  by  their  organs  of  vision,  visnels; 
and  so  on.  It  was  taught,  however,  that  by  means  of 
education  all  of  these  centres  might  be  developed  more 
harmoniously  than  they  are  usually.  The  conception  of 
the  school  of  Charcot  is  a  simpler  one  than  that  of  the 
Germans,  and  for  this  reason  it  has  been  of  service ;  but 
to  the  latter  must  be  conceded  an  ability  to  unravel  the 
intricacies  of  the  complicated  forms  of  aphasia  in  which 
the  former  fails. 

\Yhile  Charcot's  views  were  being  adopted  the  reign  of 
diagrams  began,  an  epoch  which  seems  to  us  to-day  to 
have  been  attended  principally  by  the  construction  of 
schemata  by  which  could  be  explained  theoretically  the 
different  forms  of  aphasia  that  might  occur  from  interrup- 
tion in  the  conductive,  receptive,  and  emissive  parts  of  the 
various  speech  centres.  To  an  unprejudiced  observer  at 
the  time  of  the  present  writing,  the  activity  of  this  period 
seems  to  have  been  directed  toward  constructing  a  diagram 
that  would  fit  all  possible  forms  of  aphasia,  the  builders  of 
the  diagrams  leaving  it  for  a  later  task,  and  for  others,  to 


30  The  Faculty  of  SpeecJi. 

find  cases  that  would  fit  the  theories.  The  names  that 
are  particularly  associated  with  this  period  are  Wernicke, 
Lichtheim,  Kahler,  and  Pick. 

Lichtheim,1  for  enample,  drew  a  simple  triangle,  the  an- 
gles of  which  represented  the  three  speech  centres,  audi- 
tory, visual,  and  kinaesthetic ;  and  the  lines  connecting 
them,  the  avenues  over  which  stimuli  must  travel  in  order 
to  produce  perfect  speech.  In  this  way  he  showed  that 
no  less  than  fourteen  different  areas  might  be  the  seat  of 
a  lesion  producing  aphasia.  Depending  upon  the  primary 
seat  of  destruction  and  the  segment  of  the  speech  pathway 
that  is  interrupted,  the  aphasia  that  results  will  have  indi- 
vidual and  diagnostic  characteristics.  Construction  of 
such  diagrams  and  speculation  as  to  the  form  of  aphasia 
that  might  result  soon  led  to  the  necessity  of  positing  a 
central  arrangement  for  the  interpretation  of  the  various 
stimuli  received  through  the  different  avenues  of  informa- 
tion. To  this  centre  the  name  ideational  centre  was 
given.  The  existence  of  some  such  place  of  central  re- 
ception, interpretation,  and  dissemination  was  absolutely 
necessary  when  attempts  were  made  to  subject  the  speech 
defects  constituting  aphasia  to  psychological  analysis,  and 
although  no  anatomical  proof  of  the  existence  of  such  a 
centre  could  be  furnished,  nor  from  the  conception  of  the 
very  nature  of  the  centre  could  it  be  allocated  to  any  defi- 
nite area  in  the  brain,  yet  the  reality  of  such  an  association 
area  is  universally  conceded. 

Because  of  this  recognition,  and  as  a  result  of  processes 
of  reasoning  analogous  to  that  which  led  to  the  establish- 

1  Lichtheim  :  "Aphasia."  Brain,  January,  1885. — "  Ueber  Aphasie. " 
Deutsches  Archiv  fur  klinische  Medicin,  Leipzig,  1884-85,  pp.  204-268. 


History.  3 1 

ment  of  an  ideational  centre,  grew  the  conception  of  a  pro- 
positionizing  centre  on  the  motor  side  of  the  brain  and  of 
a  naming  centre  on  the  sensory  side,  by  Broadbent.1  The 
latter  has  contended  unswervingly  for  the  reality  and 
the  existence  of  these  centres,  but  the  only  convert 
to  his  views  whose  opinion  is  of  great  importance  is 
Mills.2 

This  subject  is  referred  to  here  only  casually,  as  it 
will  be  taken  up  in  detail  and  criticised  in  another 
chapter. 

In  1 88 1  appeared  an  essay,  "  Word  Blindness  and  Word 
Deafness,"  from  the  pen  of  Mile.  Nadine  Skwortzoff, 
which  included  an  analysis  of  many  cases  of  sensory 
aphasia,  and  which  portrayed  particularly  the  teachings  of 
Magnan.  Three  years  later  this  same  side  of  the  subject, 
sensory  aphasia,  was  handled  in  a  fashion  very  creditable 
to  the  author,  Seppilli.3  In  1886  Ballet4  contributed  a 
very  thoughtful  and  serviceable  article  on  "  Internal  Lan- 
guage and  the  Various  Forms  of  Aphasia,"  and  in  the 
following  year  Ross  published  a  series  of  papers  in  the 
Medical  Chronicle  on  "Aphasia"  which  are  to-day  among 
the  most  lucid  and  trustworthy  expositions  of  the  subject 

1  Broadbent  :  "  Cerebral  Mechanism  of  Speech  and  Thought."  Med.- 
Chirurg.  Transactions,  vol.  iv.,  1872. — "Case  of  Amnesia  with  Post- 
Mortem  Examination."  Lancet,  March  2d,  1878,  p.  312. 

'Mills:  "  On  the  Localization  of  the  Auditory  Centre."  Brain,  1891. 
— "  Disorder  of  Pantomime  occurring  among  Aphasics."  Philadelphia 
Hospital  Reports,  1893,  vol.  ii.,  p.  142. 

Mills  and  McDonnell  :  "The  Naming-Centre."  Journal  of  Nervous 
and  Mental  Disease,  vol.  xx. ,  1895. 

3  Seppilli :  La  sordita  verbale  od  afasia  sensoriale. "     Riv.  Sperim.   di 
Frenatr.,  p.  94,  1884. 

4  Ballet  :    "  Le  langage  interieur  et  les  diverses  formes  de  1'aphasie." 
Th.  Agreg.,  Paris,  1886. 


32  The  Faculty  of  Speech. 

in  the  English  language.  In  these  articles  Ross  strove 
to  show,  and  succeeded  I  believe,  that  the  contentions  of 
Broadbent  concerning  a  propositionizing  centre  on  the 
motor  side  of  language  and  a  naming  centre  on  the  sen- 
sory side  were  erroneous. 

After  the  claims  for  the  separate  localization  of  graphic- 
motor  images  had  become  more  universally  urged,  dia- 
grams framed  to  explain  the  symptoms  of  aphasia  took 
on  the  shape  of  a  parallelogram,  each  angle  representing 
the  seat  of  one  of  the  allocated  functions,  the  auditory, 
visual,  motor,  and  graphic-motor,  but  which  had  the  merit 
of  distinguishing  between  the  kinaesthetic  and  the  emis- 
sive-motor sides  of  speech.  The  names  of  some  of  those 
who  made  special  study  of  agraphia  are  Charcot,  Pitres,1 
Wernicke,  Lichtheim,  and  Grasset.2 

All  this  time  there  had  been  accumulating  evidence  in 
the  shape  of  apparently  anomalous  cases  to  show  that  the 
conception  of  aphasia  as  taught  by  Charcot  and  his  school 
was  largely  erroneous,  and  the  labors  of  Dejerine  and  of 
his  pupils,  of  Serieux,  and  of  others  to  be  hereinafter  men- 
tioned, led  to  the  overthrow  of  the  reign  of  autonomous 
speech  centres. 

1  Pitres  :     "  L'aphasie   chez   les    polyglottes. "       Revue   de    Medecine, 
November,   1895. — Congres  Med.   Interne,  Lyon,   1894;  Des  Aphasies. — 
"  Agraphie   motrice   pure."       Revue   de    Medecine,   Paris,  1884,  pp.  855- 
873. — "  Recherches  sur  les  lesions  du  centre  ovale."-     These  de  Paris, 
1877.  —  "Localisations     cerebrates. "        Gaz.     Med.,     1876,     p.     474. — 
"  Aphasie    et    he'miplegie. "      Societe     Anatomique,      1875,     p.     783. — 
"Rapport   sur   les  aphasies."     Journal   de    Medecine  de  Bordeaux,  1894, 
xxiv. ,    469-481. — Gazette   Hebdomadaire  de  Medecine,   Paris,    1894,     v., 
1,365-1,370. 

2  Grasset  :   "  Localisation  dans   mal  cerebral."     Montpellier   Med.,  t. 
xl.  etxli.,  1878. — "  Cecite  et  surdite  verbales."    Montpellier  Med.,  1884, 
pp.  29-50.  — "  Des  diverses  varietes  cliniques  d'aphasie."     Nouveau  Mont- 
pellier Med.,  T5th,  22d,  2gth  February,  1896. 


History.  33 

The  contributions  of  Dejerine'  bearing  on  the  subject 
of  aphasia  deserve  special  mention.  As  early  as  1879  ne 
made  an  autopsy  on  a  patient  who  during  life  had  such 
symptoms  that  the  diagnosis  of  subcortical  motor  aphasia 
was  made,  and  the  autopsy  fully  corroborated  it.  This 
contribution  was  one  of  the  first  to  show  the  necessity  of 
differentiating  cortical  and  subcortical  aphasia,  although 
perhaps  to  Pitres  more  than  to  any  other  individual  writer  is 
due  our  knowledge  of  subcortical  motor  aphasia,  to  which 
he  turned  his  attention  as  early  as  1877.  The  really  im- 
portant contributions  of  Dejerine  to  the  subject  of  aphasia 
are  embodied  in  a  few  short  communications  to  the  Societe 

1  Dejerine  :  "  Aphasie  et  cecite  des  mots."  Progres  Medical,  p.  629  ; 
Bull,  de  la  Societe  Biologic,  Juin,  iSSo. — -"Aphasie  et  he'miplegie  droite. 
Disparition  de  1'aphasie  au  bout  de  neuf  mois.  Lesion  du  faisceau  pediculo- 
frontal  infe'rieur  gauche,  du  moyau  lenticulaire  et  de  la  partie  anterieure  de 
la  capsule  interne."  Societe  Anatomique,  1879,  p.  16. — "  De  1'aphasie  et 
de  ses  differentes  formes  ;  e't'ides  de  semiotique  et  de  physiologic  patholo- 
gique."  Semaine  Medicale,  Paris  1884,  second  series,  iv. ,  421-449. — 
"  Contribution  a  1'etude  anatomo-pathologique  et  clinique  des  differentes  vari- 
ete's  de  cecite  verbale."  Me'moiresde  la  Societe  Biologic,  1892,  p.  61. — "  Sur 
un  cas  d'aphasie  sensorielle  (cecite  et  surdite  verbales),  suivi  d'autopsie." 
Societe  Biologic,  1891,  pp.  167-173. — "Sur  un  cas  de  cecite  verbale  avec 
agraphie."  Autopsie.  Societe  Biologic,  1891,  pp.  197-201. — "  De  1'agra- 
phie."  Lecon  clinique.  Annales  de  Me'decine,  1891. — "Contribution  a 
1'etude  des  troubles  de  1'e'criture  chez  les  aphasiques."  Societe  Biologic  Me- 
moires,  1891,  p.  97-113. — "Aphasie  motrice  sous-corticale  et  localisation 
cerebrale  des  centres  larynges  (muscles  phonateurs)."  Societe  Biologic, 
1891,  pp.  155-162. — "Etude  sur  1'aphasie  dans  les  lesions  de  1'insula  de 
Reil."  Rev.  Med.,  1885,  pp.  174-191.  — "  L'aphasie  et  ses  formes." 
Semaine  Med.,  1884,  Xos.  44et47. — "  Remarques  apropos  de  la  communica- 
tion de  MM.  Charcot  et  Dutil."  Societe  Biologic,  1893,  p.  200. — "Aphasie 
sensorielle."  Bulletin  Me'dical,  March  2oth,  1895. — "  Remarques  a  propos 
de  la  communication  de  M.  Mirallie."  Societe  Biologic,  March  3Oth,  1895. 

Dejerine  and  Mirallie:  "La  lecture  mentale  chez  les  aphasiques 
moteurs  corticaux."  Societe  Biologic,  July  6th,  1895. 

Dejerine  et  Vialet  :  "Contribution  a  1'etude  de  la  localisation  anato- 
miquedela  cecite  verbale  pure."  Societe  Biologic,  29  Juillet,  1893,  p.  793. — 
"  Autopsie  de  cecite  corticale."  Societe  Biologic,  9  Decembre,  1893. 

3 


34  The  Faculty  of  Speech. 

de  Biologic  in  the  years  1891-95.  In  these  he  estab- 
lished the  dependence  of  sensory  agraphia  upon  loss  of 
visual  memories  in  the  angular  gyrus,  which  causes  alter- 
ation of  internal  language  due  to  loss  of  visual  images, 
associated  with  word  blindness.  He  combated  success- 
fully the  existence  of  a  separate  centre  for  the  registra- 
tion and  storage  of  graphic  images.  Moreover,  without 
directly  polemicizing  against  the  teachings  of  Charcot 
concerning  the  autonomy  of  the  various  centres  in  which 
are  stored  the  different  memory  images,  his  contributions 
were  of  the  greatest  worth  in  tending  to  offset  these 
views. 

Dejerine  also  did  much  to  establish  clearly  the  distinc- 
tion between  word-blindness  due  to  loss  of  visual  memories 
in  the  angular  gyrus  (which  is  always  associated  with  dis- 
turbance of  internal  language,  agraphia,  and  paraphasia, 
and  never  with  hemianopsia  if  the  lesion  is  strictly  con- 
fined) and  word  blindness  due  to  lesion  between  the  higher 
visual  centres  and  the  primary  or  true  visual  area  in  the 
occipital  lobes.  His  contentions  were  in  accord  with  the 
pathological  findings  of  Henschen  and  the  anatomico- 
pathological  and  clinical  claims  of  Seguin,  and  were  of 
such  unique  and  convincing  nature  that  there  has  been 
little  hesitation  in  accepting  them.  Dejerine  had  in  a 
pupil,  Vialet,  one  fully  worthy  of  his  master.  The  contri- 
bution of  this  brilliant  young  physician,  entitled  "  The 
Cerebral  Centres  of  Vision  and  the  Intercerebral  Visual 
Nervous  Apparatus,"  published  in  1893,  will  serve  to 
perpetuate  his  name. 

The  findings  and  interpretations  of  Dejerine  were 
corroborated  by  the  cases  carefully  observed  clinically 


History.  35 

and    fully    reported    anatomically    by     Serieux1    and    by 
Berkhan.2 

In  1893  and  1894  Wyllie's  comprehensive  lectures  on 
the  disturbances  of  speech  appeared.  In  these  a  review 
of  the  status  of  speech  disturbances  was  given,  and  in  the 
chapters  on  aphasia  particular  attention  devoted  to  the 
separation  of  the  forms  of  motor  aphasia  and  to  an  attempt 
at  localizing  psycho-motor  images  and  the  area  in  which 
such  are  stored.  Wyllie's  treatise3  compels  admiration  be- 
cause of  the  evidence  of  industry  and  perspicaciousness  on 
every  page.  But  all  in  all,  the  chapters  on  aphasia  are  not 
quite  so  critical  as  the  period  and  the  accessible  material 
would  seem  to  justify.  Reference  to  one  chapter  may 
suffice  to  show  this.  Although  he  is  duly  appreciative  of 
the  value  of  Dejerine's  contributions,  and  apparently  up- 
holds his  contentions,  he  nevertheless  proceeds,  in  a  half- 
hearted way,  to  indite  a  chapter  on  graphic-motor  aphasia  as 
an  individual  condition.  But  even  the  believer  in  such  a 
centre  must  be  disappointed  in  reading  it,  for  the  author 
does  not  make  so  strong  a  presentation  as  could  be  made 
from  the  material  at  hand.  In  the  following  year,  Freund,4 
of  Breslau,  published  a  short  monograph,  the  thesis  of  which 
was  that  the  conception  of  so-called  subcortical  sensory 
aphasia  is  entirely  too  narrow  and  limited.  He  furnishes 

'Serieux:  "  Aphasie  ;  cecite  verbale,  agraphie,  he'miplegie  gauche. " 
Societe  Anatomique,  1891,  p.  258. — "  Sur  un  cas  d'agraphie  sensorielle  avec 
autopsie."  Memoiresde  la  Societe  Biologic,  1891,  p.  195. — "  Cas  de  cecite 
verhale  avec  autopsie."  Societe  Biologic,  16  Janvier,  1892. — "  Cas  de  sur- 
dite  verbale  pure."  Rev.  Med.,  1893,  xiii.,  pp.  733-750. 

2  Berkhan  :   "  Ein  Fall  von  subcorticaler  Alexie."     Archiv    fur  Psychia- 
tric, Bd.  xxiii.,  1892,  H.  2,  S.  92. 

3  \Yyllie  :   "  Disorders  of  Speech,"  Edinburgh,  1894. 

4  Freund  :      "  Labyrinthtaubheit      und       Sprachtaubheit,"    Wiesbaden, 
1895. 


36  The  Facility  of  Speech. 

clinical  observations  of  his  own  and  analyzes  others  from 
the  literature  (one  of  which  is  strangely  enough  a  case 
that  Wernicke  utilized  originally  to  substantiate  the  oc- 
currence of  this  form  of  aphasia)  to  show  that  the  symp- 
tom complex  as  originally  described  by  Wernicke  must 
be  enlarged  to  include  labyrinthine  disease,  and  perhaps 
other  forms  of  affections  of  the  peripheral  auditory  appa- 
ratus. He  supports  his  contentions  by  citations  from 
Freud,  from  Pick,  from  Adler,  from  Bleuler,  and  from 
other  writers. 

In  the  same  year  Redlich1  gave  a  most  detailed  re- 
port, clinical  and  pathological,  of  a  case  of  pure  word- 
blindness,  which  is  a  model  of  its  kind  and  which  de- 
serves to  be  mentioned  as  an  example  to  be  followed  in 
making  communications  on  this  subject.  In  1896  Mi- 
rallie," a  pupil  of  Dejerine,  reviewed  his  teacher's  work, 
made  an  analysis  of  the  cases  of  sensory  aphasia  which 
have  been  recorded  with  autopsy  findings,  published  sev- 
eral new  observations  of  sensory  aphasia,  and  gave  a 
resume  of  the  status  as  represented  by  the  school  of 
Dejerine  to-day. 

In  the  following  year  appeared  an  apologist  for  the 
contentions  of  Brissaud,  echoing  the  teachings  of  Char- 
cot.  Lantzenberg3  aims,  apparently,  in  his  brochure  on 
"  Motor  Aphasia"  to  do  for  his  teacher  what  Mirallie  did 
for  Dejerine.  This  opuscle,  which  contains  nothing  new 
or  original,  as  well  as  three  important  English  contribu- 
tions, appeared  after  the  completion  of  the  writer's  mono- 

1  Redlich  :  "  Ueber  die  sogenannte  subcorticale  Alexie."  Jahrbuch  fiir 
Psychiatric  und  Neurologic,  vol.  xiii.,  1895. 

4  Mirallie  :   "  L'aphasie  sensorielle,"  Paris,  1896. 
3  Lantzenberg  ;   "  L'aphasie  motrice,"  Paris,  1897. 


History.  3  7 

graph,  and  reference  to  them  is  here  interpolated  to  show 
that  interest  in  the  phenomena  of  the  dissolution  of  speech 
is  not  on  the  wane.  Of  these  contributions  in  the  Eng- 
lish language,  Bastian's1  was  most  eagerly  awaited.  One 
of  the  pioneers  in  the  subject,  one  whose  early  utterances 
on  aphasia  have  been  shown  by  time  to  be  astoundingly 
unerring,  has  had  opportunity  to  look  over  the  entire  field, 
to  review  the  subject,  and  to  modify,  to  reiterate,  and  to 
recant.  In  another  part  of  this  work  I  shall  approach 
some  of  his  claims  with  the  deference  and  criticalness  to 
which  they  are  entitled.  Another  English  writer,  Bram- 
well,2  of  Edinburgh,  one  of  our  most  trustworthy  expound- 
ers of  the  intricacies  of  neurology,  reviewed  in  the  same 
year  a  number  of  extremely  interesting  cases,  and  illumi- 
nated in  discussing  them  some  of  the  most  obscure  and 
debatable  points  on  the  subject.  On  the  whole,  his  con- 
clusions are  very  much  in  accord  with  those  of  Dejerine, 
Mirallie,  and  the  present  writer.  The  last  of  the  three 
above-mentioned  contributions  is  that  of  Elder,3  who  has 
made  a  painstaking  and  careful  study.  His  conclusions 
reflect  the  teachings  of  Wyllie  and  evidence  his  disciple- 
ship. 

Thus  even  a  general  view  of  the  history  of  aphasia 
suffices  to  show  that  this  symptom  has  attracted  the  at- 
tention of  many  men  and  minds  during  the  past  third  of 
the  nineteenth  century.  It  shows  also  that  aphasia,  the 

1  Bastian  :  "  The  Lumleian  Lectures  on  Some  Problems  in  Connection 
with  Aphasia."  Lancet,  April  3d,  loth,  24th  ;  May  ist,  1897. 

'-'  Bramwell  :  "  Illustrative  Cases  of  Aphasia."  Lancet,  March  2Oth 
and  27th,  1897. 

3 Elder:  "Aphasia  and  the  Cerebral  Speech  Mechanism,"  London, 
1897. 


38.  The  Mechanism  of  Speech. 

explanation  of  which  seemed  so  clear  and  so  little  liable 
to  variation,  after  the  publication  of  Broca's  cases,  is  in 
reality  one  of  the  most  complex  problems  to  which  the 
physician  can  direct  his  attention.  The  brief  survey  that 
I  have  taken  gives  inadequate  consideration  to  the  writ- 
ings of  some  whose  work  has  been  of  the  most  important 
kind,  and  leaves  unmentioned  the  names  of  many  who  have 
contributed  materially  to  the  understanding  of  aphasia  and 
the  interpretation  of  its  intricacies,  and  without  mention 
of  which  the  history  of  aphasia  should  not  be  written. 
Such  names  include  those  of  Pick,1  Hammond,2  Ferrier,3 
Eskridge,4  Wilbrand, &  Berlin,6  Grashey,7  Soury,8  Sachs9 
(Breslau),  Starr,  10  Henschen, "  Thomas  and  Roux,  12 

1  Pick  :  Archiv  fur  Psychiatric,  t.  xxiii.,  p.  896.      "  Beitrage  zur  Lehre 
von  den  Storungen  der  Sprache,"  1892. — "  Zur  Lehre  von  der  Dyslexic." 
Neurologisches  Centralblatt,  1891,  pp.  130-132. — "  Ein  Fall  von  transcor- 
ticaler,  sensorischer  Aphasie."  Neurologisches  Centralblatt,  1890,  pp.  646- 
651. — ' '  Xeue  Beitrage  zur  Pathologic  der  Sprache."    Archiv  fur  Psychiatric, 
vol.  xxviii. ,  1896. 

2  Hammond  :   "  Treatise  on  Diseases  of  the  Nervous  System." 

3  Ferrier  :   "  Lectures  on  Localization  in  the  Brain."     Brain,  May,  1898. 
— Croonian  Lectures,  London,  1890. 

4  Eskridge  :   ' '  Symptoms  of    Speech  Disturbance   as   Aids  in  Cerebral 
Localization."     University  Medical  Magazine,  January,  1897. 

5  Wilbrand  :   "Die  Seelenblindheit   als  Hirnerscheinung,"  Wiesbaden, 
1887. 

6  Berlin  :   "  Weitere  Beobachtungen  liber  Dyslexic  mit  Se'ctionsbefund." 
Archiv  fiir  Psychiatric,  1887,  pp.  289-292. 

1  Grashey  :  "  Ueber  Aphasie  und  ihre  Beziehungen  zur  Wahrnehmung. " 
Archiv  fur  Psychiatric,  vol.  xvi.,  1885. 

8  Soury  :   "  Les  fonctions  du  cerveau,"  Paris,  1892. 

9  Sachs  :   "  Ueber  Bau  und  Thatigkeit  des  Grosshirns  und  die  Lehre  von 
der  Aphasie  und  Seelenblindheit,"  Breslau,  1893. 

10  Starr  :   "  Sensory  Aphasia."     Brain,  1889, .pp.  82-101. 

"Henschen:  "  Klinische  und  anatomische  Beitrage  zur  Pathologic  des 
Gehirns,"  Upsala,  1890-96. 

14  Thomas  and  Roux:  "  Aphasiques  moteurs  corticaux,"  etc.  Societe 
Biologic,  1895,  pp.  531,  731,  733;  and  1896,  p.  210. 


History.  39 

Strieker,1  and  many  other  writers  in  the  three  great 
languages  of  science.  They  in  their  own  ways  and  in 
their  own  times  have  added  facts  that  prevent  their 
names  from  being  forgotten. 

'Strieker,  S.:    "  Zur  Lehre  vender  Aphasie."     Wiener  medizinische 
Blatter,  1881,  iv.,  1,477-1,509,  1,565. 


CHAPTER    III. 

AN    ANALYSIS    OF   THE    GENESIS    AND    FUNCTION    OF 
SPEECH. 

I.  General  Expressive  Reactions ;  Mimic  Reactions. 
2.  Articulate  SpeecJi.  J.  Writing.  4.  The  Gen- 
esis of  Percepts.  5.  Remarks  on  Visual  Sensation; 
Acoustic  Sensation,  and  the  Mechanism  of  Articu- 
lation. 

AN  introductory  analysis  of  the  so-called  faculty  of 
speech,  from  the  psychological  point  of  view,  must  con- 
sider:  (i)  the  function  of  vocal  articulation  and  of 
writing  as  phenomena  of  bodily  movement ;  and  (2)  the 
sensational,  ideational,  and  other  antecedents  or  stimuli 
provocative  of  these  exhibitions  of  complex  motorial  co- 
ordination; and  (3)  the  development  of  the  function  of 
speech.  I  shall  limit  the  inquiries  at  the  outset  to  vocal 
speech,  considering  the  faculty  of  writing  as  subsidiary 
and  as  following  upon  the  analysis  that  I  shall  now  pro- 
ceed to  make  of  the  relationship  of  speech  to  other  forms 
of  expression,  and  of  its  mental  and  physical  antecedents. 

Vocal  speech  must  be  regarded  as  one,  and  that  the 
most  important,  mode  of  expression.  In  addition  to 
words,  articulate  and  written,  the  human  being  expresses 
his  thoughts  and  feelings  by  gesture,  by  pantomime,  of 
which  the  conventional  signs  of  the  manual  language 


The  Genesis  and  Function  of  Speech.        41 

taught  to  deafmutes  is  a  variety,  or  by  means  of  inarticu- 
late cries.  A  wave  of  the  hand,  a  contraction  of  the  mus- 
culature of  the  face,  the  expanding  or  contracting  aper- 
ture of  the  eye,  the  cry  of  pain,  the  start  of  fright,  are 
all  manifestations  or  expressions  of  bodily  condition.  The 
most  highly  developed  and  most  exact  form  of  expression 
is  found  in  words ;  but  the  individual  who  says,  "  I  am 
angry,"  has  given  expression,  it  is  true,  to  a  state  of  mind 
in  set  phrases  which  require  for  their  exclamation  a  much 
more  far-reaching  examination  of  nervous  and  mental 
processes  than  does  the  note  of  anguish ;  but  nevertheless 
the  two  present  analogies,  and  we  may  safely  consider  the 
former  as  a  development  and  outgrowth  from  the  latter- 
simpler  mode  of  mental  expression. 

It  must  be  remembered  that  these  externalizations  or 
expressions,  whatever  they  may  be,  are  manifestations  of 
the  reaction  of  the  individual  organism  to  its  environ- 
ment. So  far  as  concerns  our  present  analysis  the  en- 
vironment acts  upon  the  individual  through  his  sense 
organs.  In  this  preliminary  treatment,  I  shall  consider 
only  the  group  of  sensations  that  are  known  as  the  visual, 
the  auditory,  and  the  kinaesthetic. 

A  stimulus  acting  upon  sense  organs  tends  to  the  pro- 
duction of  bodily  changes.  These  bodily  changes  to  a 
certain  extent  depend  in  character  upon  the  nature  of  the 
stimulus.  The  organism  reacts  with  different  bodily  move- 
ments to  a  strong  and  to  a  weak  light.  It  makes  differ- 
ential responses  to  the  color  red  and  to  the  color  blue. 
The  organism  of  the  child  will  react  differently  to  the 
objects  of  its  environment  than  will  that  of  the  man.  In 
the  life  of  the  individual,  the  reacting  organism  is  there- 


42  The  Faculty  of  Speech. 

fore  modified  so  that  certain  differences  in  the  resultant 
responses  to  stimuli  must  be  considered  as  dependent 
upon  its  stage  of  ontogenesis.  Again,  the  reacting  or- 
ganism of  the  human  being  responds  in  a  different  man- 
ner to  the  same  stimuli  of  the  environment  that  act  upon 
it  than  does  that  of  a  dog  or  a  pigeon,  a  lizard  or  an  amceba ; 
in  other  words,  the  character  of  the  reacting  organism  is 
dependent  upon  its  stage  of  phylogenesis.  Biology  is  the 
science  to  which  we  must  have  recourse  for  an  explana- 
tion of  these  variations  of  type.  Again,  the  sight  of  the 
bottle  produces  upon  the  hungry  child  different  responses 
from  those  brought  out  by  the  same  object  acting  upon 
a  child  whose  appetite  is  satisfied.  Thus  the  organism 
at  every  stage  of  phylogenesis  and  ontogenesis  is  subject 
to  characteristic  modifications  which  manifest  themselves 
in  the  differences  of  reaction.  In  substance,  therefore, 
the  expressive  movements  of  the  organism  made  in  re- 
sponse to  external  excitation  are  subject  to  variations 
that  are  referable  in  part  to  differences  in  the  stimuli, 
the  stage  of  organism  development,  and  to  temporary 
changes  in  its  condition.  The  nervous  system  is  the 
centre  for  the  production  of  these  reactions ;  certain  parts 
of  it  seem  to  be  of  greater  importance  than  others.  In 
the  human  being  the  cerebral  cortex  is  the  portion  of 
the  nervous  system  which  is  chiefly  modified  by  succes- 
sive ontogenetic  variations.  It  is  that  portion,  conse- 
quently, which  is  most  educated  in  the  lifetime  of  an  indi- 
vidual, and  in  an  adult  its  destruction  in  whole  or  in  part 
is  fraught  with  the  most  serious  consequences  to  his  men- 
tal life.  The  cerebral  cortex  enregisters,  perhaps  as 
changes  of  its  substance,  effects  of  past  stimuli.  These 


/ 


The   Genesis  and  Function  of  Speech.        43 

have  been  called  by  the  name  of  memory  residua.  With- 
out such  memory  residua  and  the  association  or  grouping 
of  past  experiences  with  present  experiences,  modification 
of  the  organism  would  be  impossible.  Therefore,  if  a 
visual  stimulus  acts  upon  the  eye,  and  produces  some 
bodily  change,  the  result  of  that  stimulus  is  to  produce 
some  mark  or  trait  which  is  left  upon  the  cells  of  the 
cerebral  cortex.  If  after  innumerable  stimulations  the 
organism  of  the  child  reacts  to  the  face  of  its  mother  in 
a  manner  different  from  that  which  it  did  in  the  first  few 
days  or  months  of  its  existence,  it  does  so  because  that 
same  visual  stimulus  now  acts  upon  a  brain  which  has 
been  modified  to  such  an  extent  that  past  visual  stimuli 
of  a  similar  nature  are  evoked  simultaneously,  and  to- 
gether with  them  are  auditory  and  kinaesthetic  impres- 
sions and  recollections  of  bodily  well-being,  such  as  being 
fed,  and  so  on.  Although  all  parts  of  the  organism  re- 
spond more  or  less  intensely  to  every  excitation,  still 
certain  portions  of  the  body  and,  more  narrowly,  certain 
regions  of  the  cerebral  cortex  seem  to  be  foci  of  the  bod- 
ily disturbance  evoked  by  a  stimulus,  and  loci  for  those 
modifications  that  we  have  called  memory  residua.  Thus, 
there  are  centres  for  visual  impression  locally  differen- 
tiated from  those  of  auditory  impression,  and  these 
two  again  locally  differentiated  from  those  of  muscular 
impression. 

The  simplest  mental  consequence  of  the  stimulation  of 
a  sense  organ  by  an  external  object  may  be  assumed  to 
be  the  arousal  of  a  sensation.  A  more  complex  resultant 
is  the  arousal  of  a  perception  of  an  external  object.  The 
flower  violet  may  call  up  a  simple  sensation  of  color,  or  it 


44  The  Faculty  of  Speech. 

may  arouse  in  the  mind  the  perception  of  an  object  of 
certain  form,  color,  odor,  taste,  and  even  of  certain  habitat. 
The  arousal  of  a  perception  requires  the  conjoint  action 
or  simultaneous  association  of  disparate  sensation  groups. 
To  perceive  the  purple  violet  requires  the  conjoint  action 
of  kinaesthetic,  visual,  tactile,  and  olfactory  sensory  groups. 
To  perceive  bell  requires  most  of  these,  with  the  addition 
of  the  auditory  group.  If  we,  without  the  stimulation  of 
a  sense  organ,  call  up  in  mind  the  flower  violet,  we  evoke 
through  central  excitation  the  same  sensory  group.  To 
ideate  requires  the  successive  and  simultaneous  grouping 
of  these  after-images  of  perception,  the  so-called  memory 
images.  No  one  can  carry  on  a  train  of  thought  for  any 
length  of  time  without  being  aware  of  the  sensory  origin 
and  basis  of  the  contents  of  most  of  his  ideas.  In  some 
persons  one  group  predominates  in  initiating  in  the  zone 
of  language  the  process  that  results  in  internal  or  external 
speech.  If  the  auditory  group  predominates,  such  a  person 
may  be  called  an  auditif,  it  being  understood  that  the 
auditory  images  are  relatively  and  not  absolutely  pre- 
dominant. For  instance,  if  I  am  an  anditif,  and  in  my 
mind  I  fail  to  observe  the  visual  and  articulatory  ele- 
ments, it  is  not  because  these  are  not  acting  at  all,  but 
because  they  are  not  acting  with  sufficient  intensity  to 
arouse  consciousness  or  to  stimulate  the  frontal  lobes  to 
activity,  while  the  auditory  images  are  acting  with  suffi- 
cient intensity  and  stimulatability.  In  a  similar  way,  one 
may  be  a  visuel,  an  articulomoteur,  etc.  The  latter  indi- 
vidual is  fairly  well  represented  by  the  person  who  has 
to  think  aloud,  and  who,  as  he  thinks,  has  to  articulate 
that  upon  which  he  cogitates.  Ability  to  reason,  to 


The   Genesis  and  Function  of  Speech.        45. 


46  The  Faculty  of  Speech. 

carry  on  a  train  of  abstract  thought,  to  recognize,  and  to 
remember,  are  dependent  for  their  full  preservation  and 
for  their  development  upon  the  integrity  of  these  several 
sensory  systems.  It  is  probable,  however,  that  the  subtle 
and  complex  co-ordinations  requisite  for  the  processes  of 
abstract  thought  are  dependent  upon  ganglion  cells  having 
a  different  location,  whose  activity  is  superadded  to  that 
of  those  which  are  functional  in  the  less  complicated 
processes  of  sensory  perception. 

There  are  many  facts,  biological,  physiological,  anatomi- 
cal, and  pathological,  which  point  to  the  frontal  lobe€  as 
the  seat  of  those  neural  processes  whose  function  subserves 
the  purposes  of  a  physical  basis  for  the  higher  or  more 
complex  processes  of  the  mind ;  and  although  it  is  believed 
by  the  writer  that  there  is  no  special  centre  of  attention, 
or  of  thought,  or  of  apperception,  or  of  morality,  in  the 
frontal  lobes,  it  can  be,  nevertheless,  truthfully  main- 
tained that  the  integrity  of  the  frontal  lobes  is  essential 
to  the  full  exercise  of  the  human  being's  powers  of  com- 
plex thought. 

If  we  designate  (Fig.  i)  by  V  the  centre  for  visual 
memories,  by  A  the  centre  for  auditory  memories,  and  by 
K  the  centre  for  kinaesthetic  memories,  we  may  connect 
these  three  centres  by  a  line  which  will  indicate,  first, 
that  for  full  and  complete  perception  the  integrity  of  these 
three  centres  is  essential,  so  that,  even  if  a  stimulus 
reaches  the  brain  through  the  eye,  it  will  not  evoke  per- 
ception unless  it  succeeds  in  passing  through  appropriate 
channels  from  the  visual  to  the  auditory  and  to  the  kinaes- 
thetic centres.  Let  us  further  represent  by  C  a  hypo- 
thetical centre  or  area  for  conception ;  we  shall  then  draw 


The  Genesis  and  Function  of  Speech.        47 


FIG.  2. — Diagram  o£  Speech  Centres  and  Conception  Area. 


48  TJie  Faculty  of  Speech. 

a  line  from  C  to  V,  another  from  C  to  A,  and  another 
from  C  to  K  (Fig.  2).  In  ideation  it  is  probable  that 
all  of  these  centres,  C,  V,  A,  and  K,  are  co-ordinated  in 
action,  and  that  the  various  halves  must  be  unbroken.  In 
a  case  of  visual  conception,  that  is,  if  full  recognition  of 
an  object  that  is  seen  is  to  be  had,  it  is  most  important 
that  the  tract  from  F"to  C  be  kept  open  ;  and  for  an  audi- 
tory recognition,  that  the  tract  from  A  to  C  be  kept  open. 
It  will  be  observed  that  we  make  no  sharp  distinction  be- 
tween the  centre  for  ideas  and  the  centre  for  visual  impres- 
sion. They  are  not  in  reality  separated,  as  represented 
here  for  purposes  of  demonstration,  with  fibres  connecting 
them.  The  centres  are  rather  to  be  looked  upon  as  the 
end  of  a  series,  the  abstract  idea  being  at  one  end  and 
the  simple  sensation  at  the  other.  I  might  illustrate  it 
better  by  comparing  it  to  the  waves  in  a  pond  into  which 
a  stone  has  been  cast.  At  the  centre  of  the  irradiating 
waves  is  the  simple  sensation ;  the  waves  farthest  from 
the  centre  represents  the  concept  or  abstract  ideas.  For 
convenience'  sake,  and  in  nowise  to  be  considered  a  defi- 
nite centre,  we  let  the  letter  C  represent  the  area  for  the 
formation  of  concepts,  and  V,  A,  and  K  represent  re- 
spectively the  centres  for  visual,  auditory,  and  kinses- 
thetic  perceptions.  We  shall  now  add,  to  complete  the 
figure,  other  points  along  the  line  of  conduction  to  these 
several  centres.  Adjacent  to  V  (Fig.  3)  we  place, 
joined  thereto  by  a  line,  the  circle  marked/'  V.  This 
circle  represents  the  primary  visual  centre,  or  the 
centre  of  simple  visual  sensation.  From  this  tract  run 
two  others,  v,  v,  and  from  them  we  lead  by  two  tracts 
V  R,  which  we  shall  assume  to  represent  the  retinae. 


The   Genesis  and  Function  of  Speech.          49 


.  3.— Diagram  of  Speech  Centres  and  their  Projection. 


50  The  Faculty  of  Speech. 

/The  intermediate  v  and  v  we  assume  to  represent  the  basal 
ganglia.  The  construction  is  similar  for  the  acoustic  tracts 
and  for  the  kinaesthetic  tracts.  If  we  now  add  to  the 
figure  a  motor  tract,  the  central  portion  represented  by  5 
and  its  termini  by  s,  s,  s,  s,  which  are  supposed  to  rep- 
resent the  several  parts  of  the  several  nerves  or  neuraxons 
going  to  the  musculature  involved  in  articulatory  speech, 
we  have  the  figure  complete.  The  muscles  of  speech 
are  induced  to  contract  by  impulses  that  start  from  the 
lower  end  of  the  Rolandic  area,  to  which  impulses  have 
been  sent  from  the  zone  of  language  directly  or  indirectly 
from  the  higher  intellectual  areas,  but  always  through  the 
speech  area.  In  other  words,  the  frontal  lobe  cannot 
act  on  the  part  of  the  projection  tract  which  func- 
tionates in  externalizing  speech,  without  first  sending 
its  impulses  to  the  speech  area.  The  impulses  from  the 
cortex  go  to  the  end  of  the  primary  motor  neurons, 
that  is,  to  the  motor  nuclei  in  the  oblongata  or  in 
the  basal  ganglia. 

believe  that  the  first  cries  of  an  infant  are  purely 
automatic,  nearing  reflex  acts ;  the  same,  for  instance,  as 
respiration.  Their  occurrence  is  conditioned  by  peripheral 
stimuli  which  manifest  their  excitation  in  the  pons,  ob- 
longata, and  basal  ganglia,  in  which  lie  the  nuclei  of  origin 
of  the  cranial  nerves  innervating  the  musculature  which 
must  contract  in  order  to  produce  crying  sounds.  Such 
cries  and  sounds  are  produced  as  well  by  an  anencephalic 
child  as  by  a  child  with  a  cerebrum.  In  fact,  at  its  birth 
a  child  is  practically  without  a  functioning  cerebrum,  and 
in  this  respect  it  is  no  better  off  for  the  time  being  than 
its  anencephalic  brother.  Shortly  after  birth  the  brain 


The  Genesis  and  Function  of  Speech.        51 

begins  to  mature,  and  it  does  so  by  the  protons  of  the 
neurons  developing  myelin  sheaths ;  in  other  words,  by 
the  medullation  of  fibres.  The  fibres  passing  to  and  from 
the  brain  develop  myelin  sheaths  and  functionability 
synchronously;  in  fact,  the  latter  is  entirely  impossible 
without  the  former.  The  first  paths  to  become  medul- 
lated  are  those  destined  to  carry  sensory  impulses.  This; 
is  in  fullest  accord  with  psychological  teachings  that  sen-( 
sation  conditions  motion.  Gradually  the  individual  fibres 
of  these  sensory  pathways  become  medullated  one  after 
another,  the  first  being  the  olfactory  and  the  last  the 
auditory.  The  lateness  of  development  of  the  audi- 
tory pathway  has  important  ontogenetic  significance  and  a 
direct  bearing  on  the  monitorship  of  auditory  over  other 
images,  which  is  referred  to  in  another  chapter.  If  one 
studies  the  anatomy  of  the  brain  according  to  the  develop- 
mental method,  each  sensory  pathway  can  be  traced  dis- 
tinctly to  its  termination,  which  is  not  diffuse,  but  lim- 
ited to  sharply  circumscribed  areas,  such  as  witnesses  the 
visual  area,  limited  to  the  occipital  cortex  in  the  imme- 
diate vicinity  of  the  calcarine  fissure.  These  areas  may 
be  looked  upon  as  internal  sense  organs,  or  as  areas  that 
mirror  the  activity  of  the  peripheral  sense  organs.  De- 
struction of  them  causes  total  destruction  of  the  corre- 
sponding sense.  Thus,  destruction  of  the  visual  area  pro- 
duces blindness ;  destruction  of  the  auditory  area  produces 
deafness ;  destruction  of  the  somaesthetic  area1  produces 
loss  of  the  bodily  feeling.  Each  one  of  these  strictly  de- 
limited areas  is  in  relation  with  a  higher  area,  which  one 
may  call  an  association  area  if  he  is  satisfied  with  Flech- 

1  Flechsig's  Korpergeflihl-Area. 


52  The  Faculty 'of  Speech. 


sig's  nomenclature.  In  a  portion,  at  least,  of  such  areas 
are  stored  the  memories  of  previous  experiences,  of  pre- 
vious functionings,  and  the  materies  of  storage  is  called 
memory  images.  Before  such  memory  images  can  be 
\  stored  or  enregistered  they  must  be  produced,  and  before 
they  are  produced  the  pathways  that  conduct  the  impulses 
must  have  been  finished. 

/When  the  newborn  child  utters  a  scream  or  a  shriek, 
At  does  so  reflexly;  the  sound  is  neither  an  emotional  nor 
/  a  cognitive  expression,  and  no  anatomical  structure  above 
V^the  brain  ganglia  is  necessary.  As  it  grows  older  and 
the  brain  ripens  by  the  development  of  sensory  pathways 
and  of  terminal  areas  that  have  already  been  mentioned, 
impulses  begin  to  be  conducted  along  these  pathways. 
,Vhen  the  child  screams  after  these  pathways  are  devel- 
oped, a  kinaesthetic  impulse  going  from  the  muscles  that 
externalize  the  scream  (which  by  the  way  are  in  part  the 
muscles  that  externalize  speech :  the  muscles  of  expira- 
tion and  of  laryngeal  action)  is  sent  along  this  pathway  to 
the  Rolandic-area  cortex,  and  memories  of  it  are  stored 
up  in  an  adjacent  sensory  area,  the  foot  of  the  third  fron- 
tal  convolution.  Later,  when  the  auditory  conducting 
fibres  ripen  and  the  auditory  area  becomes  a  reality,  these 
impulses,  likewise,  are  conducted  to  its  area,  in  which 
they  are  enregistered  as  sounds,  but  not  as  differentiated 
sounds ;  for  not  until  the  child  begins  to  develop  intel- 
lectually does  its  auditory  word  area  develop.  Neverthe- 
less, these  autogenetic  and  slightly  differentiated  sounds, 
as  well  as  heterogenetic  sounds,  are  making  their  impress 
upon  the  general  auditory  field  and  are  the  outrunners  to 
prepare  it  for  the  reception  of  articulate  sounds,  which 


The  Genesis  and  Function  of  Speech.        53 

the  child  makes  later  in  response  to  auditory  and  to  visual 
stimuli. 

It  is  not  alone  kinaesthetic  memories  that  such  inarticu- 
late sounds  store  up  in  the  speech  area.  The  inco-ordi- 
nate  contraction  of  muscles  causes  some  change  in  the 
motor  cells  of  the  Rolandic  cortex  (to  which  the  great 
central  sensory  pathway  goes)  which  may  have  a  decided 
bearing  on  the  readiness  with  which  these  same  peripheral 
muscles  contract  later  in  life  in  externalizing  emotional 
and  cognitive  states  when  the  child  becomes  possessed  of 
consciousness  and  intellect. 

Every  contraction  of  the  musculature  of  speech  sends 
impulses  along  the  tract  KK  (Fig.  3),  which  are  carried  to 
the  sensory  and  percept  centre  and  are  there  joined  in  si- 
multaneous association  or  co-ordination  with  sensations  or 
percepts  that  were  aroused  by  the  original  stimulus  passing 
up  the  tract  Ww  AA.  At  a  later  period,  after  these  asso- 
ciations have  become  well  fixed,  we  find  inarticulate  cries 
giving  place  to  persistent  articulated  ones.  We  find,  fur- 
ther, the  beginning  of  speech  imitation,  which  is  prob- 
ably due,  in  the  first  instance,  to  a  stimulus  that,  passing 
from  the  tract  AA,  gives  rise  to  a  motor  impulse  running 
down  the  tract  SS,  which  in  turn  causes  such  articu- 
late co-ordination  that  the  resultant  vocal  response  is 
more  or  less  an  approximation  to  the  sound  that  causes 
it.  This  vocal  response  is,  of  course,  the  source  of  two 
ingoing  impulses,  one  up  the  tract  KK,  the  other  up 
the  tract  AA,  both  of  them  giving  rise  to  appropriate 
sensations  and  perceptions  which  in  the  consciousness 
of  the  child  supply  the  material  for  a  comparison,  and 
under  the  renewed  stimulus  of  imitation  lead  to  a 


54  The  Faculty  of  Speeck. 

constantly  nearer  approximation  to  the  original  sound. 
It  is  not  necessary  for  us  to  regard  the  centres  that  in 
this  diagram  are  represented  as  being  located  within  the 
cerebral  cortex  as  taking  part  in  the  production  of  this 
responsive  adaptation.  The  action  is  probably  more  or 
less  reflex;  it  is  a  condition  of  echolalia,  and  the  cross- 
connection  between  the  sensory  and  motor  tracts  is  prob- 
ably made  very  low  down,  certainly  not  above  the  tasal 
ganglia.  At  the  same  period  of  the  development  of  the 
child  we  find  evidence  of  visual  imitation  as  the  child 
copies  the  expressions,  gestures,  and  bodily  positions  of 
those  about  him  :  it  points  as  they  point,  just  as  it  enun- 
ciates the  words  which  it  hears  them  enunciate.  This  is 
accomplished  through  the  reflex  co-ordination  of  the  visual 
with  the  appropriate  mental  tracts.  Thus  we  have  com- 
plex adaptive  movements,  gesture  and  speech,  provoked 
through  the  instinct  of  imitation,  due  to  the  constitution 
of  the  reactive  organism.  They  require  no  volitional  or 
even  ideational  antecedents,  and  yet  they  gradually  build 
up  and  develop  perception,  memory,  and  the  association 
of  these  into  what  will  be  the  framework  of  a  system  of 
conceptual  ideation. 

As  a  result  of  these  processes,  there  are  stored  up  in  the 
kinaesthetic  centre  for  articulation  motor  images  that  are 
the  result  of  reflexly  or  automatically  excited  contractions 
in  the  musculature  of  articulation,  which  serve  as  memory 
images  and  which  are  the  immediate  mental  antecedents  of 
the  words  that  are  to  be  enunciated.  The  central  motor 
speech  mechanism  consists  therefore  of  a  purely  sensory 
centre  for  motor  memory  images,  a  centre  that  is  built  up 
as  the  result  of  receptive  processes,  and  an  emissive  centre 


The   Genesis  and  Function  of  Speech.        55 

motor  in  function  but  which  has,  so  far  as  we  know,  no 
conscious  accompaniment  of  its  activity ;  which  is,  in  short, 
a  part  of  the  general  motor  area  of  the  brain,  the  part  from 
which  proceed  motor  impulses  externalizing  speech,  which 
external ization  is  the  product  of  definite  muscular  contrac- 
tion. Next  we  have  formed  at  the  end  of  the  acoustic 
tracts  a  general  auditory  area  for  the  reception  of  all 
forms  of  acoustic  phenomena.  A  definite  part  of  this 
area  is  destined  for  the  reception  of  sounds  having  precise 
and  limited  significance.  These  sounds  are  deposited 
there  partly  as  the  result  of  the  words  of  others  and  partly 
as  the  result  of  the  words  of  the  individual  himself,  and 
constitute  acoustic  verbal  images.  As  the  reflex  centres, 
so  the  cortical  centres  are  probably  closely  bound  together, 
and  these  connections  are  known  as  association  tracts. 
At  the  same  time  there  have  been  forming  in  the  visual 
centre  and  in  the  general  auditory  centre  visual  percep- 
tions and  auditory  perceptions  related  to  the  objects  of 
the  external  world,  and  these  again  related  to  the  motor, 
auditory,  and  articulatory  verbal  images  that  have  been 
invariably  associated  with  these  visual  and  acoustic  per- 
ceptions. Each  one  of  these  centres  is  in  its  turn  con- 
nected with  the  area  of  conception  in  the  frontal  lobes, 
to  which  the  zone  of  language  (a  designation  used  to 
indicate  the  part  of  the  cortical  surface  which  contains 
the  speech  centres  or  areas)  always  sends  impulses 
with  conscious  accompaniment,  and  elements  from  each 
centre  are  inextricably  interwoven  with  the  processes  of 
ideation. 

The  development  of  abstract  thought  is  to  a  great  de- 
gree dependent  upon  the  development  of  language,  internal 


56  The  Faculty  of  Speech. 

or  external.  The  name  of  an  abstract  quality  is  fre- 
quently the  only  definite  content  of  an  idea.  Many  per- 
sons do  their  thinking  in  words.  As  I  have  mentioned 
before,  it  depends  largely  upon  individual  constitution 
whether  it  be  in  auditory  verbal  signs  or  in  kinaesthetic 
verbal  symbols. 

We  are  now  in  a  position  to  consider  one  or  two  points 
of  special  interest  connected  with  the  use  of  language. 
To  see,  recognize,  and  name  an  object,  requires  an  intact 
^visual-conduction  tract  extending  from  the  retina  through 
the  external  geniculate  body,  the  anterior  quadrigeminal 
body,  and  the  pulvinar,  to  the  cortex  of  the  occipital  lobes 
by  means  of  the  optic  radiations,  and  thence  to  the  left 
angular  gyrus.  In  a  general  way,  to  see  the  object  re- 
quires only  that  part  of  the  visual  mechanism  extending 
to  the  cortex  of  the  occipital  lobe.  ATo  recognize  and  name 
it  requires  all  or  part  of  the  remainder  of  the  visual  mech- 
anism. The  recognition  and  complete  apprehension  of 
the  object  requires,  further,  that  the  lower  visual  centre 
be  in  intact  relationship  with  the  centre  of  visual  images, 
so  that  images  of  the  object  can  be  contrasted  with  past 
experiences.  If  there  have  been  no  such  past  experi- 
ences, then  the  object  is  seen  but  not  recognized  or  named. 
In  order  that  the  use,  function,  and  wider  relations  of  the 
object  may  be  recognized,  the  centre  of  visual  images  must 
be  in  intact  relationship  with  the  concept  centre.  To 
name  the  object  apprehended,  the  concept  centre  must 
either  be  in  unbroken  connection  with  the  kinaesthetic 
motor  centre  or  with  the  auditory  verbal  centre,  which  last 
must  then  be  in  connection  with  the  kinaesthetic  verbal 
centre,  or  else  the  connection  must  be  made  through  the 


The  Genesis  and  Function  of  Speech.        57 

visual  centre  to  the  auditory  and  kinaesthetic,  or  to  the 
kinaesthetic  direct.  It  is  highly  probable  that  the  first 
is  nearest  to  the  real  condition.  These  connections  being 
intact,  with  the  connection  between  the  visual  and  concept 
centre  unbroken,  we  shall  have  the  perception  of  the  object, 
followed  by  the  naming  of  it.  Similar  conditions  obtain 
in  naming  objects  which  impress  themselves  upon  the 
sensorium  through  the  ear.  It  is  true  also  of  the  under- 
standing of  spoken  language.'  To  hear  and  answer  a 
question  intelligently  requires  that  the  acoustic  conduct- 
ing tract  to  the  auditory  area  and  to  the  centre  of  audi- 
tory verbal  images  be  intact,  and  that  the  connection  with 
the  concept  centre  be  undestroyed.  It  requires  next  that 
the  outgoing  tract  from  the  area  of  conception  to  the 
kinaesthetic  verbal  centre,  or  to  the  acoustic  and  thence  to 
the  kinaesthetic  centre,  be  intact.  This  leads  to  one  remark 
concerning  spontaneous  speech,  which  is  understood  to  be 
speech  induced  by  a  train  of  ideas — an  oration,  for  example. 
In  delivering  an  oration  we  ordinarily  find  involved  only  the 
concept  centre  and  its  connection  with  the  kinaesthetic  and 
articulatory  centre.  But,  nevertheless,  in  every  instance 
the  area  of  cognition  calls  up  the  complete  formula  of 
speech  product.  The  train  of  ideas,  however,  is  the  vivid 
content  of  the  mind,  in  virtue  of  which  the  auditory  ver- 
bal portion  functionates  below  the  level  of  consciousness. 

The  Genesis  of  Percepts. 

In  considering  the  development  of  the  functions  of 
speech  from  the  psychological  point  of  view  it  is  necessary 
to  speak  briefly  of  the  constitution  of  percepts  and  of  ideas, 
of  their  relation  to  sensation  upon  the  one  hand  and  to 


58  The  Faculty  of  Speech. 

memory  images  on  the  other,  and,  lastly,  to  make  inquiry 
as  to  the  significance  of  the  verbal  symbols  for  our  ideas 
and  percepts,  and  of  the  mode  of  their  acquirement. 

The  percept  of  an  object  is  formed  of  the  collocation  in] 
our  minds  of  different  sensory  impressions  that  have  been 
aroused  in  consciousness  through  the  action  of  the  object 
upon  the  special  organs  of  sense.  Sensations  are  there- 
fore the  material  out  of  which  a  percept  is  formed.  All 
the  sensations  that  are  capable  of  being  aroused  by  an 
object  need  not  be  present  in  consciousness  at  one  time. 
In  becoming  acquainted  with  some  object  of  the  environ- 
ment (let  us  suppose  a  bell)  the  object  has  appealed  at 
different  times  to  eye,  ear,  and  touch ;  from  these  experi- 
ences of  various  senses  we  have  formed  our  idea  of  the 
nature  of  a  bell,  its  appearance,  the  sound  that  it  will 
emit  on  being  struck,  and  its  hardness  or  resistance.  If 
our  past  sensory  experiences  with  the  object  bell  have 
been  well  preserved  in  memory,  impingement  of  one  sin- 
gle quality  of  a  bell  on  the  consciousness,  through  one 
sense  organ  only,  will  be  sufficient  to  arouse  in  our  minds 
the  total  percept  of  bell,  which  will  really  be  an  aggregate 
of  the  present  sensation  and  of  the  memories  of  the  sen- 
sory impressions  of  the  past,  and  to  revivify  every  quality 
of  a  bell  and  all  it  stands  for. 

The  sensations  of  hearing  and  seeing  are  the  most  im- 
portant sources  of  perception,  and  are  those  upon  which 
we  depend  principally  to  obtain  our  knowledge  of  the 
world  about  us  and  what  goes  on  in  it.  The  other  sensa- 
tions are  used  more  for  corroborative  or  supplementary 
information.  The  formation  of  a  definite  composite  per- 
cept of  an  object  is  generally  followed  by  giving  to  it  a 


The   Genesis  and  Function  of  Speech.         59 

name.  The  name  usually  indicates  some  quality  of  the 
object,  and  in  the  beginning  the  child  calls  the  stove 
"hot,"  the  dog  "bow-wow,"  or  it  expresses  a  generality 
of  occurrences  that  a  single  conventional  expression  does 
not  even  suggest,  such  as  "  baba,"  meaning  not  only  sleep, 
but  the  paraphernalia  with  which  mothers  of  modern 
civilization  surround  the  transition  from  consciousness  to 
unconsciousness  in  their  children — the  nurse,  the  rocking 
of  the  cradle,  the  lullaby,  and  all  the  other  things  that  the 
child  has  been  accustomed  to  at  this  time.  In  the  very 
beginning  it  is  probable  that  the  names  applied  to  things 
are  entirely  imitative  and  the  association  between  the 
name  and  the  thing  comes  only  after  the  child's  attention 
has  been  repeatedly  called  to  it.  The  more  frequently 
and  persistently  his  attention  is  directed  to  it,  the  sooner 
does  the  child  learn  to  associate  the  sound  with  the  thing. 
This  is  well  illustrated  by  the  early  acquisition  and  under- 
standing of,  that  is,  the  application  of,  the  words  "  papa" 
and  "  mama."  These  sounds  are  uttered  by  the  mother, 
and,  as  they  are  easily  imitatively  produced,  and  as  the 
mother  repeats  them  persistently,  the  child  very  early 
learns  to  say  them,  and  moreover  early  learns  to  use  them 
but  not  discriminatingly,  for  in  the  beginning  every  man 
is  "papa."  In  a  very  short  time  the  sound  of  the  word 
"  papa"  calls  up  in  the  child's  mind  the  visual  memory  of 
its  father,  and  this  is  accompanied  by  numerous  expres- 
sions of  joy.  Thus  we  have  association  of  ideas  as  the 
basis  of  intellectual  process  and  the  originator  of  purpo- 
sive speech. 

Every  one  has  had  opportunity  to  observe  young  chil- 
dren, busy  with  their  toys,  repeating  over  and  over  sounds 


60  The  Facility  of  Speech. 

or  words  to  which  they  attach  no  significance,  and  which, 
if  addressed  to  them  directly,  call  up  no  memory  pictures 
in  their  minds  of  the  objects  of  which  they  are  the  names. 
This  condition  of  echolalia  indicates  the  existence  of  an 
automatic  speech  mechanism  in  the  production  of  these 
words.  The  word  is  produced  because  some  sensory 
impression  has  been  caught  up  and  is  influencing  the 
emissive  centres  to  activity.  Each  time  that  the  child 
repeats  the  word,  memories  of  a  sensory  and  motor  nature 
are  being  stored  up  and  held  in  readiness  to  be  associated 
with  their  proper  percepts.  7Thus  speech  is  the  product 
of  the  revival  of  memory  in  one  or  more  sensory  and  motor 
areas  simultaneously,  the  two  memories  blending  into  a 
..^single  consciousness.  As  I  have  said  previously,  before 
the  proper  name  has  been  associated  with  the  object,  as, 
for  example,  the  word  dog  with  a  barking  animal,  the 
child  for  a  long  time  may  associate  some  prominent  sense 
impression  which  the  dog  makes  on  its  auditory  centre, 
namely,  its  bark,  with  the  sight  of  the  dog.  In  this  con- 
dition it  recalls  the  memory  of  dog  and  refers  to  it  as 
"  bow-wow."  It  is  thus  seen  that  the  giving  of  a  specific 
name  to  an  object  is  a  more  complicated  mental  process, 
and  therefore  one  more  easily  destroyed,  than  is  the  giv- 
ing of  expressive  or  suggestive  designation  to  a  sensory 
impression. 

The  name  of  an  object,  as  well  as  the  names  of  quali- 
ties of  the  object,  is  stored  up  in  definite  parts  of  the 
brain,  and  its  retention  by  the  brain  constitutes  a  word 
memory  or  name  memory  of  the  object,  which  can  be 
drawn  upon  for  purposes  of  perception  or  thought  or 
speech,  as  are  other  memories.  The  sound  of  a  church 


The  Genesis  and  function  of  Speech.        61 

bell,  which  to  an  aborigine  would  call  to  mind  no  image 
of  belfry  or  church  building,  no  thought  of  the  material 
from  which  it  was  cast,  nor  of  its  size,  color,  and  shape, 
nor  of  the  purpose  of  its  ringing,  and  thus  would  bring 
to  his  mind  no  memory  picture  of  all  the  environmental 
associates  of  the  bell,  starts  a  sequence  of  associations  in 
the  mind  of  one  who  has  learned  of  a  bell,  which  may  be 
of  religious  worship,  of  death,  of  marriage,  of  public  calam- 
ity or  rejoicing,  and  along  with  them  it  calls  up  the  name 
which  he  has  heard  others  give  to  the  object  which  is  the 
immediate  cause  of  the  sensation. 

If  a  normally  developed  adult  person  were  to  have  that 
part  of  the  auditory  cortical  areas  destroyed  in  which  are 
stored  up  the  memory  images  of  all  percepts  obtained 
through  the  sense  of  hearing,  he  would  be  unable  to  rec- 
ognize the  sound  of  the  bell,  as  a  bell,  although  the  sensa- 
tions which  the  ringing  of  it  produced  might  be  the  same 
as  before,  and  heard  quite  as  acutely.  His  auditory  cen- 
tres have  been  reduced  to  the  simple  untutored  state  of 
the  aborigine.  An  exactly  analogous  condition  maintains 
for  percepts  that  are  formed  through  other  sense  organs, 
as,  for  example,  through  the  eye,  as  in  learning  to  read; 
and  for  the  expression  of  language  in  motor  visual  form, 
for  example,  in  writing. 

An  individual  who  has  learned  to  speak  transforms 
memory  images  of  words  and  ideas  into  spoken  or  written 
or  other  forms  of  conventional  language.  To  accomplish 
this  there  must  have  been  stored  up  in  the  brain  cortex, 
in  the  centres  of  vision,  of  audition,  and  of  kinaesthetic 
perception,  a  large  number  of  sense  impressions  which 
are  the  symbolic  representatives  of  percepts.  These  come 


62  The  Faculty  of  Speech. 

from  without  and  are  first  presented  through  the  sense 
of  hearing. 

Although  speech  is  not  absolutely  essential  to  thought, 
still  it  is  probable  that  most  persons  find  it  necessary  to 
use  words  internally  in  order  to  think.  For  some  persons, 
at  least,  thinking  is  always  accompanied  by  and  dependent 
upon  internal  speech.  A  knowledge  of  the  psychology  and 
physiology  of  internal  speech  is  very  helpful  to  the  under- 
standing of  some  aspects  of  aphasia.  Internal  speech  is 
dependent  upon  a  revival  of  auditory,  visual,  and  articu- 
latory  memories ;  its  integrity  depends  upon  the  united 
action  of  these  three  centres,  but  that  one  which  is  most 
highly  cultivated  is  revived  most  vividly.  This  special 
one  in  some  cases  reaches  such  a  stage  of  development 
that  it  seems  to  overtop  the  others;  for  instance,  some 
persons  find  it  necessary  in  speaking  to  call  up  the  visual 
images  of  the  words,  others  depend  largely  upon  the  au- 
ditory, and  still  others  upon  the  articulatory  kinaesthetic 
images.  Nevertheless,  internal  speech  is  imperfect  when 
the  speech  centre  considered  of  least  importance  in  any 
given  individual  is  in  any  way  deranged.  The  first  is  the 
most  common  and  the  second  least.  As  I  have  said  be- 
fore, Charcot  and  his  followers  refer  to  those  who  in 
speech  depend  upon  visual  memories  as  visuels,  to  those 
who  depend  upon  auditory  memories  as  auditifs,  and  to 
those  who  depend  upon  motor  memories  as  moteurs.  This 
division  is  fanciful  and  has  but  slight  practical  application 
as  has  before  been  suggested.  I  shall  have  occasion  to 
revert  to  this  point  in  the  chapter  on  "  Conception  of 
Aphasia." 

All  of  the  centres  entering  into  word  production  are 


The   Genesis  and  Function  of  SpcecJi.        63 

intimately  connected  with  one  another,  and  a  variety  of 
combinations  is  possible.  With  these  combinations  I 
shall  not  concern  myself  here. 

Clinical  experience  teaches  that  occasionally  visual  im- 
ages of  letters  and  words  are  lost,  while  those  for  ciphers 
and  other  graphic  symbols  are  preserved.  It  is  necessary, 
therefore,  to  say  a  word  here  concerning  the  acquisition  of 
such  symbols.  Ciphers  and  other  forms  of  notation  are, 
like  words,  symbols  devised  by  mankind  to  represent  cer- 
tain definite  values,  which  are  used  to  facilitate  human 
intercourse.  As  symbols  they  are  very  much  less  differ- 
entiated in  their  application  than  letters  are,  and  unlike 
letters,  which  vary  in  their  value  with  every  varying  com- 
bination and  change  of  position,  ciphers  have  given  to 
them  a  very  definite,  limited,  and  unvarying  value  which 
remains  unchanged,  it  matters  not  their  combination. 
Moreover,  they  are  not  complex  as  words  are,  but  may  be 
looked  upon  as  simple,  unvarying  substitutes  for  words. 
This  graphicness  of  registration  on  the  visual  areas  is 
shown  most  convincingly  by  a  study  of  arithmetical  prodi- 
gies. Such  persons,  as  a  rule,  have  well-defined  intellec- 
tual limitations  in  a  number  of  directions.  In  fact,  many 
of  them  belong  to  the  class  of  idiots  savans.  Such  per- 
sons are  enabled  to  perform  the  most  stupendous  arith- 
metical problems  usually  calling  only  for  primitive 
methods  of  computation.  When  the  method  by  which 
they  accomplish  this  is  analyzed,  it  is  seen  to  be  very 
simple  and  in  keeping  with  the  graphicness  of  represen- 
tation of  ciphers  in  the  visual  sphere.  Mathematical  prod- 
igies are  endowed  with  the  capacity  of  enregistering 
ciphers  so  vividly  that  they  can  see  them  as  distinctly  in 


64  The  Faculty  of  Speech. 

their  "  mind's  eye"  as  if  the  characters  were  written  on 
paper  before  them,  and  they  not  infrequently  explain  their 
methods  by  saying  they  read  off  the  figures  as  they  see 
them  in  their  mind. 

It  is  not  at  all  likely  that  there  is  a  separate  centre  in 
which  such  symbols  are  stored ;  all  the  evidence  bearing 
on  this  point  tends  to  show  that,  like  letters,  memories  of 
them  are  stored  in  the  angular  gyrus  but  that  the  registra- 
tion is  a  simpler  one.  If  this  be  so,  it  accounts  for  their 
preservation  after  letters  are  lost  and  for  the  greater  readi- 
ness with  which  they  are  evoked. 

Writing. 

The  faculty  of  writing  is  developed,  like  that  of  articu- 
late speech,  under  stress  of  the  impulse  of  imitation,  the 
co-ordination  being  one  between  the  visual  centre  and  that 
part  of  the  motor  cortex  from  which  impulses  start  to 
move  the  member  that  holds  the  pen,  whether  it  be  the 
hand  or  any  other  mobile  part  of  the  body  which  has  ac- 
quired or  is  acquiring  facility  by  practice  in  making  the 
co-ordinated  movements  of  writing.  These  movements  of 
writing  are  all  accompanied  by  the  reception  of  kinses- 
thetic  impulses  that  go  to  the  somsesthetic  area  of  the 
brain,  and  the  renewal  of  these  memories  makes  writing 
seem  in  those  who  have  had  long  practice  almost  like  an 
automatic  act,  but  in  every  instance,  it  matters  not  how 
facile  or  apparently  divorced  from  consciousness  the  act 
of  writing  may  be,  the  physiological  procedure  consists  of 
impulses  passing  through  the  same  series  of  operations  as 
it  did  in  the  beginning.  It  must  be  remembered  that  the 
motor  tracts  for  writing  and  for  speech  are  tracts  for  ex- 


The   Genesis  and  Function  of  Speech.        65 

pression  and  that  they  are  influenced  by  any  conditions 
that  influence  the  reacting  organism. 

The  motor  act  of  wielding  a  brush  in  painting  or  in 
portraying  visual  sensory  images,  whether  imaginary  or 
real,  is  done  by  a  cortical  area  quite  as  specialized  as  that 
for  writing.  When  the  child  learns  to  write,  it  does  so, 
as  has  just  been  said,  under  the  stress  of  imitation.  It 
is  first  made  to  copy  or  to  trace  letters  or  words  that  have 
been  put  before  it  in  orthodox  script.  Formerly  the  child 
was  taught  to  trace  or  copy  individual  letters.  Even 
now  this  method  is  by  no  means  obsolete,  which  it  richly 
deserves  to  be.  It  is  gratifying  to  hear  that  very  few 
of  even  the  most  "old-fashioned"  schoolteachers  require 
their  charges  to  "print"  words,  i.e.,  to  copy  them  from 
type,  a  procedure  that  was  very  common  in  bygone  days. 
Such  inculcation  was  a  striving  for  the  antithesis  of  the 
correct  method.  Most  modern  pedagogues  teach  their 
young  pupils  to  trace  or  copy  syllables  and  words  in  the 
same  way  as  they  teach  them  to  learn  syllables  and  words 
instead  of  letters.  Pedagogical  experts  are  also  maintain- 
ing as  a  matter  of  sound  principle  that  writing  with  a  pen 
should  be  taught  relatively  late  in  a  child's  educational 
career  and  should  always  be  preceded  by  writing  upon  the 
blackboard  with  free  arm  movements  from  the  shoulder, 
because  the  former  movements  being  the  result  of  more 
specialized  centres,  should  be  developed  after  and  from 
the  latter. 

In  the  beginning,  tracing  and  copying  words  and  letters 
are  a  slow  and  tedious  process,  principally,  however,  on  ac- 
count of  the  awkwardness  in  holding  and  guiding  the  pen. 
If  the  child  is  left-handed  the  awkwardness  is  more  evi- 
5 


66  The  Faculty  of  Speech: 

dent,  because  schoolteachers,  almost  without  exception, 
unless  oriented  to  the  contrary,  insist  upon  having  the 
child  write  with  the  right  hand,  notwithstanding  the  fact 
that  the  organism  is  left-handed.  This  the  child  soon 
does  with  the  same  facility  as  though  he  had  been  allowed 
to  write  with  the  left  hand. 

If  the  child  copies  or  traces  without  understanding  the 
letter  or  the  word,  the  neural  process  is  a  very  simple  one, 
and  all  that  is  required  is  that  the  cortex  of  the  brain  shall 
mirror  the  letters  and  then  the  transcription  of  these  vis- 
ual images  by  the  arm-hand  motor  area.  If,  however,  the 
child  is  being  taught  to  recognize  the  letters  at  the  same 
time,  which  is  usually  the  case,  there  are  stored  up  in  its 
higher  visual  centre  memories  which  form  part  of  the  gen- 
eral concept  of  the  letter  or  the  word.  After  the  child 
traces  or  copies  letters  for  a  time  he  acquires  a  visual 
memory  image  of  them ;  he  may  and  probably  does  at  the 
same  time  acquire  their  names  and  significance.  After 
this  he  no  longer  requires  a  copy  before  him  to  produce 
the  letters;  he  copies  the  letter  in  fact  out  of  his  visual 
storehouse.  In  the  beginning,  before  the  images  have 
been  firmly  embedded,  it  requires  strict  attention  to  evo- 
cate  these  imperfectly  enregistered  images,  and  the  whole 
process  is  done  slowly  and  laboriously.  In  fact,  often- 
times some  of  the  images  cannot  be  evoked  at  all ;  then 
they  are  said  to  be  forgotten.  But  any  one  who  has  stud- 
ied a  child  who  is  learning  to  write  knows  that  it  has  not 
wholly  lost  the  memory  of  the  word,  and  by  putting  before 
him  a  part  of  the  recalcitrant  letter  he  may  succeed  in 
revivifying  the  letter  or  the  word  of  which  it  forms  a  part. 
For  instance,  a  child  who  is  asked  to  write  the  name 


The   Genesis  and  Function  of  Speech.        67 

"  Frank"  may  say,  "  I  don't  know  how  it  begins,"  mean- 
ing that  it  cannot  jut  the  first  letter  of  the  word  with 
sufficient  vividness  into  the  zone  of  language,  and  thus  to 
the  concept  centre.  If,  however,  the  perpendicular  limb 
of  the  letter  and  the  middle  short  horizontal  stroke  is 
made  for  it,  the  child  may  go  on  and  complete  the  letter 
/'"and  the  remainder  of  the  word.  In  this  case  the  visual 
images  are  not  thoroughly  incorporated  and  need  other 
than  volitional  stimulation  to  invoke  them.  When  writ- 
ing becomes  an  habitual  act,  the  letters  and  words  which 
one  writes  form  an  integral  part  of  internal  language,  and  all 
the  images  of  words  are  evoked  simultaneously.  In  such 
voluntary  writing  an  impulse  starting  from  C  (Fig.  2)  calls 
up  the  images  in  V,  and  these  proceed  to  an  area  in  the 
motor  cortex  at  S,  but  in  every  instance  there  is  reason  to 
believe  that  this  pathway  is  through  A  and  K.  Color  is 
lent  to  this  view  by  a  study  of  writing  in  children  and  in 
those  who  learn  to  write  late  in  life.  The  fact  that  the 
articulatory  image  of  the  word  is  called  up  is  shown  by 
the  experience  that  a  word  is  always  uttered  either  articu- 
lately or  to  themselves  immediately  preceding  its  produc- 
tion. As  writing  becomes  more  automatic,  i.e.,  as  one 
becomes  more  adept  in  writing,  this  phenomenon  ceases 
entirely,  particularly  in  those  who  have  been  instructed 
"  to  keep  what  they  are  doing  to  themselves"  (a  common 
admonition  in  schools,  at  least  in  New  England  country 
schools)  ;  in  others  the  phenomenon  of  articulating  with- 
out vocalizing  the  word  is  retained  throughout  life. 

If  one  examines  himself  carefully  and  repeatedly  while 
writing,  he  is  cognizant  of  a  peculiar  feeling  or  sensation 
in  the  ears  and  throat.  These  correspond  to  the  auditory 


68  Tke  Faculty  of  Speech, 

and  articulatory  evocation  of  the  letters  and  words  that  he 
is  about  to  write  down.  It  is,  I  believe,  quite  the  same 
in  typewriters.  I  am  sure  this  phenomenon  occurs  in  my 
own  case  when  I  operate  the  writing-machine,  which  I  do 
with  rapidity  and  facility.  If  this  is  the  case  when  one 
externalizes  his  own  thoughts  by  means  of  the  writing- 
machine,  it  is  legitimate  to  inquire  if  the  same  process  or 
phenomenon  is  gone  through  when  one  writes  from  dicta- 
tion. Numerous  interrogations  of  my  stenographer,  a 
very  intelligent  man,  always  bring  the  reply  that  in  writ- 
ing from  dictation  the  words  or  the  letters  composing 
them  are  uttered  audibly  immediately  preceding  the  strik- 
ing of  the  keys,  or  this  is  preceded  by  a  feeling  of  move- 
ment and  tension  in  the  ears  and  throat,  which  are  the 
congeners  of  such  outward  word  production.  I  would  not 
be  understood  to  say  that  this  takes  place  in  every  in- 
stance. Indeed,  it  is  highly  probable  that  long  practice 
does  away  with  the  necessity  of  conscious  activity  of  the 
articulatory  centres  before  the  externalization  of  the  let- 
ters and  words  by  the  tapping  of  the  keys. 

Thus  we  have  a  series  of  functions  developing  in  suc- 
cession:  first,  general  expressive  reactions;  second,  mimic 
reactions;  third,  articulatory  speech;  fourth,  writing.  In 
cases  of  disorder  we  should  expect  the  last  to  be  the  least 
stable  and  the  first  to  be  the  most  stable,  and  our  experi- 
ence as  physicians  teaches  us  that  this  is  what  really 
occurs. 

The  following  areas  and  centres  have  been  considered : 
(i)  The  visual  area,  and  in  close  relation  to  it  the  vis- 
ual word  centre.  (2)  The  auditory  area,  and  in  close  re- 
lation to  it  the  auditory  word  centre.  (3)  The  kinaesthetic 


The  Genesis  and  Fimctton  of  Speech.        69 

area,  and  in  close  relation  to  it  the  word-image  centre,  the 
motor-articulatory  centre. 

The  position  of  these  centres  and  areas  and  the  consti- 
tution of  the  zone  of  language  by  the  former,  as  well  as 
its  environmental  relationships  to  the  different  parts  of 
the  brain,  are  pointed  out  in  the  chapter  on  "  Conception 
of  Aphasia."  The  relation  of  the  primary  visual  centre, 
the  visual  centre  for  verbal  images,  the  general  auditory 
centre,  and  the  auditory  centre  for  verbal  memories,  and  of 
the  kinaesthetic  art iculatory  centre  to  the  conception  centre 
are  highly  important.  The  centre  in  which  are  stored 
visual  images  is  adjacent  to  the  primary  visual  area.  The 
centre  in  which  are  stored  auditory  word  memories  is  in 
the  upper  part  of  the  general  auditory  area,  while  the  im- 
ages of  articulation  are  allocated  to  the  third  frontal  con- 
volution, immediately  adjacent  to  the  somaesthetic  area, 
and  to  the  motor  speech  area. 

The  destruction  of  any  one  of  these  centres  or  of  the 
connecting  links  is  liable  to  produce  the  disorder  of  speech 
known  as  aphasia.  A  consideration  of  the  most  frequent 
types  of  aphasia  with  reference  to  this  analytical  scheme 
of  speech  will  show  that  some  of  the  centres  and  their 
pathways  are  frequently  the  seat  of  lesion  and  others  less 
frequently.  It  should  be  remembered  (i)  that  the  loca- 
tion of  a  lesion  that  will  cause  aphasia  is  largely  influ- 
enced, as  far  as  frequency  of  occurrence  goes,  by  the  blood 
supply  of  that  region ;  and  (2)  that  the  amount  of  speech 
disturbance  that  a  lesion  in  the  same  locality  in  different 
brains  will  produce  will  vary  only  slightly  with  the  sen- 
sory basis  of  the  ideation  of  the  individual  to  whom  the 
brain  belongs. 


70  The  Faculty  of  Speech. 

To  complete  this  analysis  it  will  be  necessary  for  us  to 
take  up  briefly  the  various  elements  in  visual  perception, 
to  consider  (i)  color  sensations,  (2)  form,  (3)  dimen- 
sions, (4)  distance,  (5)  relation  to  the  environment.  It 
will  be  necessary  in  the  case  of  audition  to  distinguish 
between  the  hearing  of  noises,  musical  tones,  and  the 
hearing  of  articulated  words;  and  to  consider  (i) 
rhythm,  (2)  pitch,  (3)  tone  quality,  (4)  intensity,  (5) 
sound  sequence.  On  the  motor  side  similar  complica- 
tions will  be  met  with.  In  articulatory  speech  we  can 
distinguish  (i)  the  lips,  (2)  the  tongue,  (3)  the  soft 
palate,  (4)  the  nose,  (5)  the  larynx,  (6)  the  lungs,  (7) 
the  diaphragm. 

Visual  Sensation. 

In  attempting  to  analyze  the  various  elements  in  visual 
perception,  I  shall  have  to  consider  in  the  briefest  possible 
manner  the  typical  physiological  and  psychological  factors 
of  vision  and  the  relation  of  physical  and  psychological 
stimuli  to  psycho-physiological  conditions. 

I  have  previously  spoken  of  the  component  parts  of  the 
visual  mechanism,  and  here  I  shall  confine  myself  to  an 
enumeration  of  the  elements  of  the  peripheral  visual  appa- 
ratus. They  consist,  i,  (a)  of  a  neuro-epithelial  percipi- 
ent apparatus,  and  (b)  a  ganglionic  and  nerve-fibre  con- 
ducting apparatus;  2,  of  a  refractive  apparatus;,  and,  3, 
of  a  muscular  mechanism  arranged  to  move  the  eyeballs 
in  any  direction  which  may  best  contribute  to  the  placing 
of  optical  stimuli  on  the  point  of  most  acute  perceptive 
power. 

Next  in  importance  to  the  neuro-epithelial  percipient 


TJie   Genesis  and  Function  of  Speech.        71 

apparatus  is  the  muscular  mechanism  which  not  only 
moves  the  eyeballs  but  also  changes  the  shape  of  the  re- 
fractive media  that  project  the  rays  of  light  on  the  retina. 
These  muscular  actions,  some  of  which  are  continually 
being  made  during  states  of  consciousness,  and,  to  a  lim- 
ited extent  during  states  of  unconsciousness,  produce 
afferent  stimuli,  the  memories  of  which  are  stored  up 
probably  in  the  supramarginal  gyrus,  adjacent  to  or  in  the 
somaesthetic  area  to  which  they  are  directly  sent.  The 
evocation  of  kinaesthetic  ocular  memories  plays  a  part  in 
the  proper  perception  of  visual  impulses  and  contributes 
to  the  interpretation  of  visual  percepts. 

The  customary  physical  stimulant  of  vision  is  light, 
which  is  a  wave  motion  of  the  ether.  These  wave  mo- 
tions occur  with  a  rapidity  varying  from  400,000,000,000 
to  900,000,000,000  per  second.  Other  forms  of  stimuli 
than  light  may  excite  visual  sensation.  Such  are  me- 
chanical and  electrical  stimuli.  If  one  places  the  elec- 
trode carrying  a  galvanic  current  on  each  temple,  the 
make  and  break  of  the  current  are  accompanied  by  a  flash 
of  light. 

The  physical  stimulus,  luminous  vibration,  or  wave 
motions  of  ether  are  said  to  act  by  decomposing  the  vis- 
ual purple  of  the  retina,  which  procedure  indirectly  sets 
up  a  commotion  in  the  optic-nerve  filaments,  which  are 
in  connection  with  the  cells  over  which  the  photo-chemical 
substance  is  spread,  and  the  filaments  conduct  the  commo- 
tion to  the  occipital  cortex,  where  they  are  registered. 
This,  at  least,  is  the  theory  of  physiologists  and  psycholo- 
gists. No  real  proof  can  be  offered  of  the  existence  of 
such  a  process.  It  may  be  said,  indeed,  that  the  part 


72  The  Faculty  of  Speech. 

played  by  the  visual  purple  has  been  allotted  too  great  im- 
portance, as  vision  continues  after  it  is  exhausted  and  is 
not  lacking  in  animals  devoid  of  it.  Therefore  I  prefer 
to  say  that  luminous  waves  excite  the  elements  of  the 
percipient  apparatus,  probably  by  photo-chemical  means, 
which  excitation  is  carried  by  the  conducting  apparatus 
along  the  optic  nerves  and  their  continuation  to  the  oc- 
cipital cortex.  The  registration  in  the  cortex  is  not  dis- 
tributed in  a  haphazard  manner.  Certain  parts  receive 
impulses  coming  from  different  parts  of  the  retina,  so  that 
visual  impulses  coming  from  one  quadrant  of  the  retina 
are  registered  in  a  definite  and  correspondent  portion  of 
the  occipital  visual  area. 

The  three  different  substances  assumed  to  be  affected 
in  a  photo-chemical  way  by  luminous  waves  are  supposed 
to  lie  in  different  percipient  elements,  so  that  one  of  the 
primary  colors  excites  only  those  percipient  elements 
which  contain  the  substance  corresponding  to  that  color. 
Mixed  colors  excite  two  or  three  sets  of  percipient  ele- 
ments in  different  degree. 

Psychologically,  the  different  qualities  of  visual  sensa- 
tion are  known  as  color.  Different  color  sensations  are 
produced  by  the  different  colors  of  the  spectrum,  and 
these  color  sensations  differ  according  to  wave  lengths, 
the  longest  waves  being  those  at  the  red  end  of  the  spec- 
trum and  the  shortest  waves  those  at  the  blue.  The  lu- 
minous intensity  of  a  color  varies  with  the  amplitude  of 
vibration,  but  with  an  equal  amplitude  of  vibration  some 
colors  are  inherently  more  luminous  than  others.  As  the 
number  of  acoustic  vibrations  constitute  the  pitch,  so  the 
wave  length  or  number  of  vibrations  to  a  second  consti- 


The   Genesis  and  Function  of  SpeecJi.        73 

tutes  the  color.  The  relationship  existing  between  the 
intensity  of  color  sensation  and  auditory  phenomena  is  a 
close  one,  and  constitutes  the  basis  of  color  audition. 
Persons  in  whom  this  phenomenon  takes  place  apparently 
get  auditory  excitation  through  the  perception  of  certain 
colors.  This  is  not  a  physiological  interaction,  however, 
but  a  psychological  one,  and  is  often  met  with  in  psycho- 
pathic states. 

Each  percipient  element  is  not  trained  to  vibrations  of 
certain  wave  lengths,  and  therefore  not  to  the  reception 
of  individual  colors.  The  areas  of  the  retina  in  which 
the  cones  and  ganglion  cells  are  few  are  relatively  less 
sensitive  to  color  perception,  requiring  for  perception  and 
excitation  greater  intensity  or  a  stimulus  covering  a  great- 
er area. 

Before  a  child  acquires  perception  of  space  and  form,  it 
must  acquire  perception  of  color.  It  has  been  accepted 
on  the  teachings  of  Preyer  and  others  that  in  so  doing 
children  follow  such  an  unvariable  formula  that  it  may 
be  looked  upon  as  a  law.  First  they  learn  the  recogni- 
tion of  yellow,  then  of  red,  later  of  green,  and  very  much 
later  of  blue ;  in  fact,  Preyer  contends  that  the  color  blue 
may  fail  to  be  recognized  until  very  late.  Binet's  and 
Baldwin's  studies  seem  to  disprove  this  temporal  acquisi- 
tion of  color  perception.  The  latter' s  experiments  showed 
that  the  order  of  acquiring  color  perception  was  blue, 
white,  red,  green,  brown.  Much  further  experimentation 
and  observation  are  needed  on  this  point  before  it  can  be 
considered  settled.  The  acquisition  of  color  perception 
is  supposed  to  be  proportionate  with  the  maturation  of  the 
photo-chemical  substance,  whatever  that  may  be,  in  the  per- 


74  Tke  Faculty  of  SpcecJi. 

cipient  membrane.  As  a  matter  of  fact,  the  acquisition  of 
visual  perception  of  any  kind  is  dependent  upon  the  ripen- 
ing of  the  optical  neuron.  The  manner  in  which  children 
acquire  perception  of  color  can,  however,  legitimately  be 
explained  by  the  fact  that  prismatic  colors  have  different 
luminosities,  yellow  being  the  brightest,  green  and  red 
next,  and  blue  and. violet  the  dullest;  and  it  is  not  at  all 
unlikely  that  children  get  perception  of  colors  in  the  above 
order  on  account  of  these  different  luminosities. 

Visual  memories  for  form  are  the  result  of  muscular 
co-ordinations  made  in  the  movements  of  the  various  com- 
ponents of  the  eye  which  have  been  utilized  in  getting  an 
outline  percept  of  the  object,  with  the  color  sensations 
coming  from  the  object  contrasted  with  the  latter  by  the 
conceptual  sphere.  The  original  motive  of  all  ocular  mo- 
tions is  the  desire  to  perceive  objects  clearly,  and  to 
accomplish  this  we  must  of  necessity  have  the  percep- 
tion of  light  and  color,  a  conception  of  form  and  space, 
and  the  faculty  of  seeing  things  in  the  places  where  they 
are,  which  may  be  called  the  projection  of  perception. 
When  a  person  is  in  possession  of  these  three  factors,  he 
may  be  said  to  be  in  possession  of  the  means  for  fullest 
visual  orientation.  It  is  this  orientation  visually  of  ob- 
jects, animate  or  inanimate,  symbolic  or  concrete,  that 
enters  as  an  element  of  the  mind  and  as  a  most  important 
factor  in  the  evolution  of  thought  communication. 

Acoustic  Sensations. 

Acoustic  sensations  are  produced  by  wave  motions  of 
elastic  substances.  Although  the  rapidity  of  these  wave 
motions  may  vary  within  wide  limits,  a  certain  numb'er 


TJie  Genesis  and  Function  of  Speech.        75 

must  take  place  within  a  second  of  time  in  order  to  pro-, 
duce  the  sensation  of  sound.  Ordinary  sounds,  or  clangs, 
are  a  series  of  component  tones  which,  irrespective  of  their 
intensity,  can  be  distinguished  from  one  another  by  their 
tone  quality. 

The  peripheral  auditory  apparatus  consists  essentially 
of  three  parts:  (i)  of  a  neuro-epithelial  percipient  ap- 
paratus, and  a  ganglionic  and  nerve-fibre  and  conducting 
apparatus — the  organ  of  Corti,  which  has  its  origin  in  the 
cochlea;  (2)  of  the  tympanum  and  ossicles;  and  (3)  of 
the  meatus  and  the  external  ear.  There  is  another  part 
of  the  auditory  nerve  than  the  cochlear  one,  which  takes 
its  origin  from  the  ampullae  of  the  semicircular  canal,  and 
which  for  this  reason  is  called  the  vestibular  nerve.  It 
does  not  go  to  the  auditory  area;  it  has  nothing  to  do 
with  audition ;  it  goes  to  the  cerebellum  and  in  all  proba- 
bility it  is  of  paramount  importance  in  contributing  to  the 
maintenance  of  equilibrium. 

The  meatus  and  the  membrana  tympani  serve  as  pro- 
tectors to  the  terminals  of  the  cochlear  nerve.  They  act 
to  prevent  all  stimuli,  except  those  adequate  and  requisite 
to  contribute  auditory  information,  from  acting  on  these 
terminals,  and  particularly  from  acting  deleteriously  on 
them.  The  tympanum  through  its  tensor  muscle  is  ex- 
cited reflexly  to  contraction  to  meet  these  sounds  and  to 
prepare  for  them.  The  auditory  nerves  proper,  that  is, 
the  cochlear  divisions,  have  their  eventual  distribution 
in  the  superior  temporal  lobes  on  both  sides  of  the  brain 
in  what  is  called  the  general  auditory  area.  It  is  highly 
probable,  although  it  cannot  be  absolutely  so  stated,  that 
these  nerves  undergo  complete  decussation,  the  left  nerve 


76  The  Faculty  of  Speech. 

going  to  the  right  auditory  area,  and  the   right  nerve  to 
the  left  auditory  area. 

The  organ  of  Corti,  a  neurc-epithelial  structure,  lies  on 
an  expanded  membrane  composed  of  fibres  of  different 
lengths.  This  membrane  may  be  compared  to  a  harp, 
each  constituent  of  which  is  attuned  to  the  various  primi- 
tive sounds.  These  different  lengths  are  connected  with 
the  elements  of  the  organ  of  Corti,  and  it  is  probable  that 
more  than  one  are  connected  with  the  same  element  of  the 
organ  of  Corti. 

The  periodic  vibrations  that  the  ear  takes  cognizance  of 
maybe  considered  grossly  as  of  two  kinds:  (i)  musical 
sounds  or  tones,  and  (2)  noises.  Musical  sounds  are  periodic 
vibrations,  while  noises  are  irregular.  The  human  voice, 
which  may  produce  both  noises  and  musical  tones,  may 
be  taken  as  an  example  of  these  two  forms.  Musical 
sounds  or  clangs  are  very  complex  in  their  constitution, 
but  they  can  be  separated  into  simple  acoustic  elements 
or  tones.  When  musical  sounds  reach  the  human  ear 
they  are  analyzed  into  component  tones  by  the  membrane 
covering  the  organ  of  Corti,  and  this  communicates  the 
commotion  to  the  individual  organ  of  Corti,  which  is  rep- 
resented in  the  auditory  area  in  the  temporo-sphenoidal 
lobes. 

The  characteristics  of  auditory  perceptions  that  must 
be  considered  are  the  intensity,  the  pitch,  and  the  timbre. 
The  intensity  of  a  sound  depends  upon  the  amplitude  of 
the  vibration.  The  pitch  or  tone  quality  depends  upon 
the  number  of  vibrations ;  the  timbre  depends  upon  the 
number  and  relative  dominance  of  the  constituent  tones. 

Individuals  vary  greatly  in  their  discrimination  of  pitch, 


TJie  Genesis  and  Function  of  Speech.        7  7 

and  on  this  discrimination  depends  the  musical  capacity 
of  the  individual.  When  a  person  cannot  distinguish  tones 
separated  by  an  interval  corresponding  to  a  semitone  he  is 
tone  deaf.  We  shall  see  later  on  that  this  condition  may 
be  caused  by  lesion  of  the  auditory  area,  and  probably  as 
well  by  lesion  of  the  right  temporo-sphenoidal  lobe  as  by 
lesion  of  the  left. 

Each  nerve  end  of  the  cochlear  nerve  can  be  ex- 
cited by  only  one  pitch,  or  at  least  by  a  very  limited  num- 
ber of  pitches.  The  same  stimulus  of  sound  does  not  act 
at  the  same  time  upon  many  nerve  ends,  but  upon  one  or 
a  few  neighboring  terminations,  and  each  nerve  fibre  of 
the  organ  of  Corti  becomes  accustomed  and  especially  sen- 
sitive to  a  certain  pitch.  This  necessitates,  for  the  fullest 
effect  of  sounds,  the  condition  known  as  sound  sequence, 
as  there  is  no  special  sequence  in  the  arrangement  of  sev- 
eral tones  heard  simultaneously.  This,  in  connection  with 
the  fact  that  the  sensations  of  sound  are  not  projected  into 
space  with  any  exactness  or  with  any  differentiation,  al- 
though some  assume,  without  furnishing  tangible  proof, 
that  there  exists  an  auditory  field  that  can  in  a  way  be 
compared  to  the  visual  field,  necessitates  a  mechanism  of 
great  selective  or  differentiating  capacity.  The  only  ac- 
cessory means  of  determining  the  locality  from  which 
sounds  proceed  is  by  turning  the  head,  as  the  human  ear 
lacks  a  muscular  apparatus  especially  contrived  to  put  the 
trumpet  external  ear  in  different  positions  to  aid  the  local- 
ization. Thus  no  kinaesthetic  sensations  of  any  import, 
except  those  connected  with  the  tensor  tympani  muscles, 
enters  into  the  auditory  memories,  nor  are  any  sent  to  the 
general  somassthetic  area. 


78  The  Faculty  rf  Speech. 

Articulation. 

In  the  analysis  of  the  mechanism  of  articulatory  speech, 
I  must  discuss,  first,  the  part  played  by  respiration,  or,  to 
be  more  specific,  by  expiration ;  the  parts  concerned  in 
phonation;  and  the  parts  concerned  in  articulation,  using 
the  word  in  its  limited  sense.  The  expiratory  cur- 
rent is  the  absolute  sine  qjia  non  of  phonation,  and  the 
following  characters  of  expiration  have  to  be  considered, 
viz.,  the  rapidity,  the  rhythm,  and  the  force.  Expira- 
tion, as  well  as  the  entire  respiratory  act,  is  a  reflex  act 
which  is  often  described  as  an  automatic  act.  It  is  not 
automatic  in  the  strict  sense  of  the  term.  Its  integrity  is 
vouched  for  by  a  centre  consisting  of  two  parts,  an  inspi- 
ratory  and  an  expiratory,  situated  in  the  oblongata,  and  the 
functional  activity  of  this  centre  stands  in  very  close 
relationship  to  the  state  of  the  blood.  This  is  shown 
by  the  overactivity  of  the  centre  in  cases  of  anaemia 
and  by  the  cessation  of  activity  in  cases  of  superoxida- 
tion. 

The  respiratory  function  is,  nevertheless,  under  the  di- 
rect influence  of  the  will,  and  can,  within  certain  limits, 
be  subject  to  considerable  change,  and  particularly  it  can 
be  influenced  in  its  rapidity,  rhythm,  and  force.  Consid- 
eration of  this  fact  leads  one  to  believe  that  there  is  a 
distinct  representation  for  the  thoracic  and  laryngeal  res- 
piratory movements  in  the  motor  cortex,  and  that  this  area 
can  be  stimulated  to  activity  by  impulses  coming  from  the 
higher  intellectual  area,  either  directly  by  force  of  the 
will,  or  indirectly,  as  by  fear  and  joyful  emotions.  There 
is  some  experimental  evidence  to  show  the  location  of 


The   Genesis  and  function  of  Speech.        79 

this  respiratory  centre  to  be  in  the  upper  part  of  the 
lower  third  of  the  ascending  frontal  convolution.  That 
is,  it  is  adjacent  to  the  centres  for  movement  of  the  lips, 
tongue,  and  larynx,  in  the  lower  part  of  the  Rolandic  re- 
gion. 

The  expiratory  current  is  necessary  for  all  phonic  phe- 
nomena and  for  articulation,  and  in  fact  they  are  depen- 
dent upon  it.  This  can  be  easily  demonstrated  if  one 
attempts  to  articulate  or  phonate  at  the  end  of  a  full  in- 
spiration. Not  a  tone,  not  an  articulate  sound  can  be 
produced  until  the  lungs  have  taken  some  air  in  that  can 
go  out  in  expiration.  The  degree  of  perfection  of  articu- 
late speech  depends  upon  the  rapidity,  rhythm,  and  force 
of  expiration,  as  witness  the  phonation  and  articulation  of 
a  patient  suffering  with  dyspnoea  or  with  marked  asthenia, 
such  as  that  accompanying  Asiatic  cholera.  In  the  latter 
the  patient  is  as  toneless  and  as  inarticulate  as  if  he  had 
a  tracheotomy  tube  in  the  windpipe.  Yet  such  patients 
are  in  full  possession  of  their  mental  faculties,  including 
that  of  internal  language,  if  the  statements  of  those  who 
recover  can  be  relied  upon. 

The  expiratory  current  is  the  motor  power  that  sets  the 
vocal  cords  into  vibration.  The  vocal  cords  may  be  con- 
sidered simple  bands  of  fibre-elastic  tissue,  having  a  mar- 
vellously arranged  muscular  mechanism  which  is  capable 
of  putting  them  in  different  states  of  tension  and  of  relax- 
ation. The  expiratory  current  setting  the  cords  in  motion 
originates  all  the  different  series  of  air  waves  of  which  the 
voice  is  composed.  After  these  series  of  air  waves  have 
been  started  by  the  cords  they  are  modified  by  the  reso- 
nance cavities.  These  resonance  cavities  are  controlled  by 


So  77/6'  Faculty  of  Speech. 

the  muscles  surrounding  them,  the  principal  ones  of  which 
are  those  of  the  pharynx,  mouth,  and  nose.  They  rein- 
force the  air  waves  set  up  by  the  vocal  cords  and  thus  give 
character  to  the  tone.  The  tone  as  it  leaves  the  cords  is . 
a  mere  squawk,  and  would  always  remain  \  i  were  it  not 
for  the  resonance  cavities.  Moreover,  without  resonance 
cavities  we  could  not  articulate. 

The  vocal  cords  originate  several  different  tones,  prob- 
ably eight  or  ten,  all  the  time,  and  it  is  the  blending  of 
these  different  tones  that  constitutes  the  "  timbre"  of  the 
voice. 

The  number  and  relative  strength  of  these  different 
partial  tones  determine  the  quality  of  the  tone,  and  here 
it  may  be  said  that  the  different  vowel  sounds  are  simply 
changes  in  quality  of  the  tone.  This  is  brought  about  by 
changing  the  size  and  shape  of  the  resonance  cavities,  so 
that  they  reinforce  some  of  the  tones  started  by  the  cord 
and  suppress  others.  For  example,  the  vowel  a,  as  in 
fatlicr,  in  a  good  voice  may  have  ten  partial  tones,  with 
the  lowest  pitch  strongest  and  the  tones  gradually  dimin- 
ishing in  strength  as  they  rise  in  pitch.  There  must  be  a 
certain  position  of  the  tongue,  lips,  and  soft  palate  to  pro- 
duce this  result.  These  positions  of  the  lips,  tongue,  and 
palate  in  the  same  individual  would  always  give  the  same 
combination  of  partial  tones,  and  this  combination  of  par- 
tial tones  would  always  give  the  vowel  a.  To  articulate 
the  vowel  c  there  must  be  a  change  in  position  of  these 
parts.  In  the  vowel  a  the  tongue  is  in  a  low  position  in 
the  mouth,  giving  a  large  resonant  space  there.  In  the 
vowel  e  the  tongue  is  raised  so  that  it  fills  the  mouth  cav- 
ity, thus  destroying  it  as  a  resonance  chamber.  The 


The  Genesis  and  Function  of  Speech.        81 

effect  is  to  suppress  all  the  tones  except  the  first 
four,  and  of  these  the  second  is  strongly  reinforced. 
For  the  long  a  we  have  another  position  of  the  articulat- 
ing muscles,  and  hence  another  combination  of  partial 
tones,  and  so  on  through  the  whole  list  of  vowels.  The 
consonants,  on  the  other  hand,  are  merely  interruptions  of 
the  vowel  sounds  produced  by  the  use  of  the  tongue  and 
the  lips.  Without  the  expiratory  currents  we  could  not 
produce  the  sound,  and  without  the  resonance  cavities  we 
could  not  articulate,  as  they  are  the  only  means  by  which 
we  change  the  character  of  the  sound,  and,  after  all,  that 
is  what  articulation  is  in  reality. 

The  degree  of  perfection  of  articulate  speech  depends 
largely  on  the  use  made  of  the  resonance  cavities;  in 
other  words,  the  use  of  the  muscles  that  change  their  size 
and  shape.  The  force  of  the  expiratory  current  affects  the 
intensity  of  the  tone,  and  the  intensity  of  the  tone  is  de- 
termined by  the  height  of  the  air  waves  of  which  the  tone 
is  composed.  The  altitude  of  the  air  waves  depends,  first, 
upon  the  extent  of  motion  of  the  vocal  cords.  It  is  not 
thought  necessary  here  to  enumerate  the  factors  that  affect 
the  pitch  of  the  tone,  or  to  describe  the  variations  that 
such  causative  factors  may  undergo  by  the  contraction  of 
the  muscles  which  control  the  activities  of  the  cord.  Suffi- 
cient, it  is  believed,  has  been  said  to  show  that  a  number 
of  composite  factors  enter  into  the  production  of  articulate 
speech  as  a  mode  of  externalizing  thought.  It  will  be 
seen  that  the  essential  element  in  them  all  is  one  con- 
ditioned by  muscular  action  :  expiration  by  action  of  the 
diaphragm  and  other  expiratory  muscles,  tension  of  the 
vocal  cords  by  the  intrinsic  musculature  of  the  larynxr 


82  The  Faculty  of  Speech. 

change  in  the  shape  and  size  of  the  resonance  cavities  by 
the  muscles  which  enter  largely  into  the  constitution  of 
surrounding  parts.  It  will  be  seen,  moreover,  that  three 
different  sets  or  groups  of  muscles,  or  possibly  four,  par- 
take of  this  composite  act :  the  respiratory,  the  laryngeal, 
the  lingual,  and  the  buccal.  Each  set  or  group  of  these 
muscles  has  a  definite  representation  in  the  Rolandic 
area  of  the  cortex,  specifically  in  the  inferior  part  of 
the  ascending  frontal  convolution,  immediately  adja- 
cent to  the  third  frontal  convolution.  From  experimen- 
tal and  pathological  evidence  it  is  believed  that  the 
representation  for  each  of  these  muscles  is  very  strictly 
defined. 

All  the  phenomena  constituting  articulation  are  under 
the  direct  control  of  the  will.  When  consciousness  is  ex- 
ternalized in  words  of  different  phonic  and  articulatory 
characteristics  the  words  are  framed  in  the  zone  of  lan- 
guage, and  appropriate  stimuli  are  sent  to  the  cortical 
motor  area  in  which  are  represented  the  parts  concerned 
in  phonation  and  articulation.  The  conscious  impulse 
that  is  responsible  for  their  being  starts  also  impulses 
that  modify  them  and  give  them  the  qualities  that  have 
just  been  enumerated.  '  There  exists  between  the  cortical 
speech  mechanism  and  the  peripheral  speech  mechanism 
an  intervening  mechanism  whose  function  is  to  regulate 
and  co-ordinate  the  impulses  coming  from  above.  This 
may  be  considered  a  subsidiary  station,  and  it  is  situated 
at  the  level  where  the  peripheral  axones  of  those  neurons 
of  the  cortico-motor  tract  whose  function  it  is  to  carry 
motor  and  articulatory  impulses  undergo  end  arboriza- 
tion, i.e.,  in  the  pons-oblongata.  Whether  this  subsidiary 


The  Genesis  and  Function  of  Speech.        83 

station  has  all  to  do  in  co-ordinating  and  regulating  the 
different  elements  of  articulatory  impulses  cannot  at  the 
present  time  be  said.  It  is  thought,  however,  that  it  is 
very  largely  concerned  in  this  function. 

The  child  in  learning  articulate  speech  brings  into  play 
a  very  composite  motor  mechanism.  In  the  beginning, 
before  the  impulses  starting  from  the  cortex  are  properly 
co-ordinated,  and  before  the  child  has  learned  how  to  use 
its  external  speech  apparatus,  articulation  may  be  defec- 
tive in  many  ways.  As  soon,  however,  as  the  co-ordinat- 
ing centre  for  these  cortical  impulses  performs  its  func- 
tion in  the  intended  manner  the  externalization  of  speech 
becomes  perfect. 

Although  I  have  no  intention  of  discussing  in  this 
chapter  the  dissolution  of  speech,  but  propose  to  confine 
myself  entirely  to  the  genesis  of  speech,  it  may  be  well 
to  call  attention  to  the  completeness  with  which  externali- 
zation of  speech  can  be  lost  by  a  destruction  of  that  part 
of  the  cortex  in  which  are  located  the  motor  centres  for 
the  respiration,  the  larynx,  and  the  resonance  mechanism. 
Such  a  destruction  may  constitute,  as  we  shall  see  later, 
the  lesion  of  subcortical  motor  aphasia,  a  lesion  that  pro- 
duces as  complete  aphemia,  without  in  any  way  interfer- 
ing with  internal  speech,  as  if  the  patient  were  devoid  of 
an  external  speech  mechanism.  It  must  also  be  seen,  I 
think,  that  a  lesion  that  severs  all  the  projection  fibres 
coming  from  these  areas,  it  matters  not  at  what  level — as 
far,  in  fact,  as  the  termination  of  the  primary  motor  neu- 
ron— would  produce  exactly  the  same  result.  As  a  matter 
of  experience,  we  have  learned  that  a  subcortical  lesion,  to 
cause  complete  aphasia,  must  be  situated  very  close  to  the 


84 


The  Faculty  of  Speech. 


cortex,  and  the  reason  for  this  is  not  far  to  seek.  As  far 
as  possible,  nature  attempts  to  make  up  for  its  apparent 
shortcomings  by  substitution,  and,  as  it  is  a  necessity  to 
send  all  the  motor  projection  tracts  through  an  extremely 
small  space,  the  internal  capsule  at  the  base  of  the  brain 
(Fig.  4),  it  is  probable  that  it  does  not  send  the  projection 
fibres  coming  from  the  various  articulatory  parts  of  the  cor- 
tex in  which  are  situated 
the  representation  of  res- 
piration, laryngeal,  buc- 
cal,  and  labial  move- 
ments in  a  direct  way 
from  the  centre  to  the 
,  subsidiary  station  through 

*•  '       the    same    part    of    the 

capsule.  Therefore  a 
lesion,  unless  it  is  suffi- 
ciently great  to  cut  across 
the  internal  capsule, 

FIG.  4.— Position  of  Different  Fibres  Con- 
stituting the  Internal  Capsule,  after  Van    vVOUld     not     at      the     level 
Gehuchten.    i,  Cortico-thalamic  ;  2,  mixed 

motor  fibres   from  the  cortico-protuber-    of  the  latter  produce  dpJlC- 
antial  fibres  ;  3,  sensory  fibres  ;  CW,  cau- 
date nucleus  ;  T,  thalamus  ;  LN,  lenticu-    fttta,     but     WOLlld,     rather, 
lar  nucleus. 

produce  a  dysarthric  dis- 
turbance of  speech.  As  lesions  so  extensive  as  to  cut 
across  the  internal  capsule  are  rarely  consistent  with  life, 
we  do  not  meet  with  this  form  of  subcortical  aphasia. 

A  few  sentences  devoted  to  the  word  as  a  phonetic  phe- 
nomenon and  we  must  take  leave  of  this  part  of  the  anal- 
ysis. A  word  varies  phonetically  according  to  the  lan- 
guage that  it  is  a  constituent  of.  In  the  languages  of 
civilized  people  it  is  an  acoustic  phenomenon,  phoneti- 


The  Genesis  and  Function  of  Speech.        85 

cally  differentiated,  to  which  such  peoples  have  given  a 
definite  value  as  an  expressive  sign.  In  the  language  of 
some  uncivilized  peoples,  such  as  the  Chinese,  the  value 
of  each  sound  or  word  varies  with  the  intonation,  and  a 
study  of  aphasia  in  a  Chinese  subject  would  be  of  great 
service  in  illuminating  the  part  played  by  expiration  as  a 
psycho-motor  act,  for  this  conditions  intonation. 


CHAPTER    IV. 
CONCEPTION  OF  APHASIA. 

I.  Remarks  on  the  Anatomy  of  the  Brain.  2.  Zone  of 
Language.  Site  of  Revival  of  Words  in  Silent 
Thought.  3.  Evidence  in  Favor  of  and  against  tJic 
Existence  of  a  Special  Graphic  Motor  Centre. 

BEFORE  outlining  the  conception  of  aphasia  which  I  ven- 
ture to  believe  is  the  one  most  in  accord  with  anatomical, 
physiological,  psychological,  and  pathological  evidence, 
and  before  discussing  the  theories  or  ideas  of  aphasia  that 
have  held  sway  in  the  past,  as  well  as  those  taught  to-day, 
I  shall  outline  as  briefly  as  possible  the  parts  of  the  brain 
concerned  in  the  faculty  of  speech.  To  do  this  under- 
stand! ngly  it  is  necessary  to  take  a  survey  of  the  architec- 
ture and  anatomy  of  the  brain  in  general,  and  particularly 
to  describe  explicitly  the  connections  of  the  different  parts 
or  centres  that  are  known  as  speech  centres. 

No  one  will  dispute  that  the  cerebral  hemispheres  are 
necessary  for  the  maintenance  of  the  faculty  of  speech. 
No  one  will  be  likely  to  contend,  having  in  mind  the 
studies  of  Goltz,  that  the  cerebral  hemispheres  are  neces- 
sary for  the  maintenance  of  life  in  the  higher  animals.  It 
is  well  known  that  this  investigator  was  able  to  keep  a 
dog  alive  for  a  considerable  time  after  he  had  completely 
extirpated  both  cerebral  hemispheres.  The  dog  was 


Conception  of  Aphasia.  87 

devoid  of  memory  and  judgment,  and  incapable  of  find- 
ing out  for  himself  the  things  necessary  for  the  sat- 
isfaction of  his  needs;  nevertheless,  he  could  stand  and 
run,  and  he  responded  to  direct  stimuli,  such  as  a  blow, 
light,  noise,  etc.  When  he  was  deprived  of  nutrition  the 
whole  body  was  agitated,  and  when  he  had  eaten  abun- 
dantly he  became  content  and  showed  evident  signs  of 
satisfaction.  That  absence  of  the  cerebral  cortex  is  con- 
sistent with  life  is  shown  by  many  cases  of  anencephalic 
monsters  whose  histories  have  been  recorded.  Moreover, 
it  has  been  shown  by  Flechsig  that  the  infant  at  birth, 
and  for  a  short  time  after,  is  practically  in  the  same  con- 
dition as  a  child  without  cerebral  hemispheres.  The  child 
is  unable  to  make  any  conscious  acts,  all  its  movements 
and  responses  are  reflex,  and  not  until  the  ripening  of  the 
cortex  begins  by  the  development  of  myelin  sheaths  for 
each  nerve  fibre  has  the  cortex  any  functioning  ability. 
Flechsig  has  demonstrated  beyond  any  question  of  doubt, 
and  many  other  scientists  have  corroborated  the  demon- 
stration, that  the  nerve  fibres  of  the  hemispheres  develop 
their  myelin  sheaths  at  different  periods  of  the  infant's 
life,  that  those  destined  to  function  first  are  the  first  to 
develop  myelin  sheaths,  while  those  destined  to  function 
later  develop  them  at  a  different  time.  By  means  of  this 
method  of  investigation  the  anatomist  of  Leipzig  has 
shown  that  the  fibres  serving  different  functions  can  be 
followed  with  almost^  mathematical  precision  to  the  parts 
of  the  cortex  in  which  they  terminate,  or  from  the  parts  of 
the  cortex  whence  they  go  toward  the  periphery.  This 
method  of  investigation  has  put  him  in  possession  of  facts 
of  such  indisputability  that  it  becomes  necessary  to  re- 


88  The  Faculty  of  Speech. 

model,  if  not  entirely  to  reconstruct,  some  previous  teach- 
ings of  the  anatomy  of  the  brain,  and  particularly  of  theo- 
ries built  in  consonance  with  such  teachings.  Of  such 
theories,  that  of  aphasia  is  not  one  of  the  least  important. 
Flechsig's  teachings  of  what  may  be  called  the  physio- 
logical structure  of  the  brain  do  not,  however,  clash  ma- 
terially with  the  present  topographical  teachings,  although 
they  point  to  the  uselessness  of  dividing  the  cerebral  hem- 
ispheres into  a  number  of  lobes  and  lobules  for  any  other 
purpose  than  that  of  simple  topographical  orientation. 
Bearing  this  in  mind,  it  may  be  said  that  the  cortex  of 
the  brain  is  divided  naturally  by  primary,  principal,  or 
complete  fissures  (using  the  term  complete  fissures  in  the 
sense  of  His)  into  the  frontal,  temporal,  occipital,  parie- 
tal, and  insular  lobes.^The  fissures  by  which  such  divi- 
sion is  made  are  the  fissure  of  Sylvius,  the  central  fissure, 
and  the  parieto-occipital  fissure.  The  fissure  of  Sylvius 
is  the  one  that  particularly  concerns  us  now,  for  about  it 
the  so-called  zone  of  language  is  builE/  The  fissure  of 
Sylvius  is  one  of  the  first  markings  to  show  itself  in  the 
embryonic  state.  It  appears  at  about  the  fourth  week  of 
intra-uterine  life  as  a  large  depression  on  the  external  sur- 
face of  the  cerebral  vesicle,  or  that  part  of  it  destined  to 
be  the  forebrain.  The  forebrain  grows  and  expands  tow- 
ard the  front  and  backward,  in  fact  in  every  direction  ex- 
cept outward ;  consequently  there  is  left  a  depression  at 
the  lateral  surface  which  corresponds  to  the  position  of 
the  corpus  callosum  internally.  This  depression  consti- 
tutes the  fossa  of  Sylvius  (Fig.  5).  As  the  brain  con- 
tinues to  develop  and  to  rotate  on  its  axis,  and  the  various 
parts  of  the  hemispheres  approximate  one  another,  this 


Conception  oj  Aphasia, 


89 


space  becomes  narrowed ;  the  portion  of  the  cortex  lying 
at  the  bottom  of  it  is  covered  over,  and  is  known  later  as 
the  island  of  Reil,  while  the  prolongations  of  the  space 
become  very  much  narrowed  and  constitute  the  limbs  of 
the  fissure  of  Sylvius.  This  elongation  of  the  fossa  of 
Sylvius  takes  place  at  about  the  fourth  month.  On  ac- 


PIG.  5.— Triangular  Fossa  Sylvii  (foetal  brain). 

count  of  the  disproportionate  development  of  the  occipi- 
tal lobe,  this  elongation  is  directed  obliquely  upward  and 
backward.  The  various  parts  bordering  the  fossa  of  Syl- 
vius, developing,  extend  into  the  fossa  as  well  as  in  other 
directions,  and  these  interfossal  projections  form  lids  or 
opercula,  which  are  designated  frontal,  parietal,  and  tem- 
poral, according  to  the  lobe  of  which  they  are  a  part.  Thus, 
when  the.  fissure  of  Sylvius  is  completed,  the  parts  of  the 


go  The  Faculty  of  Speech. 

cortex  that  extend  into  the  fossa  of  Sylvius,  which  it  is 
to  be  remembered  was  originally  a  large  triangular  space, 
are  known  as  opercula — the  inferior  operculum  being 
formed  by  the  anterior  part  of  the  temporal  lobe,  the  sup- 
erior operculum  formed  in  part  by  the  frontal  and  in  part 
by  the  parietal,  the  anterior  operculum,  the  shortest,  con- 
stituted by  the  frontal  lobe.  When  the  operculum  alone 
is  mentioned,  the  superior  operculum  is  always  meant,  for 
it  is  in  reality  the  important  one. 

The  fissure  of  Sylvius  in  the  fully  developed  brain  is 
a  most  striking  feature.  It  starts  from  the  fossa  of  Syl- 
vius, which  is  just  lateral  to  the  anterior  perforated  space, 
passes  forward  and  upward  to  the  lateral  surface  of  the 
brain,  where  it  divides  into  a  short  anterior  horizontal 
branch,  and  a  posterior  ascending  branch  which  continues 
backward  obliquely  across  the  external  surface  of  the  cere- 
brum and  terminates  in  a  bifurcation  near  the  middle  of 
the  lateral  surface,  this  point  being  usually  in  the  inferior 
parietal  lobule.  The  posterior  limb  gives  off  immediately 
after  the  beginning  of  its  oblique  course  a  short  anterior 
vertical  branch,  which  juts  into  the  inferior  frontal  con- 
volution and  cuts  off  a  portion  of  the  convolution  which  is 
known  as  the  "foot."  The  Sylvian  fissure  separates  the 
frontal  and  the  parietal  lobes  above  from  the  temporal 
lobe  below.  At  its  bottom  is  the  most  important  annec- 
tant  convolution  of  the  hemisphere,  the  island  of  Reil. 
^The  frontal  convolutions  are  named  superior,  middle, 
and  inferior,  the  latter  alone  being  of  interest  to  us  now 
on  account  of  the  physiological  importance  attributed  to 
it  in  the  production  of  speech,  or,  to  be  more  specific,  I 
should  say,  attributed  to  the  left  inferior  frontal  convolu- 


Conception  of  Aphasia.  91 

tion  when  the  organism  is  right-handed,  and  to  the  right 
inferior  frontal  convolution  when  the  organism  is  left- 
handed.  This  convolution  is  usually  known  as  the  con- 
volution of  Broca.  It  borders  the  fissure  of  Sylvius  be- 
low, and  posteriorly  it  is  continuous  with  the  ascending 
frontal  convolutioiy  The  anterior  horizontal  limb  of  the 
fissure,  and  the  much  more  insignificant  branch  of  the  fis- 
sure of  Sylvius,  the  anterior  vertical  branch,  jut  into  the 
convolution  of  Broca. 

These  branches  of  the  Sylvian  fissure  divide  the  infe- 
rior frontal  convolution  into  three  parts  : 

1.  The  opercular  part,  or  foot   of  the  convolution   of 
Broca,  situated  in  front  of  the  lower  extremity  of  the  an- 
terior central  convolution  and  comprised  between  the  pre- 
central   fissure  and    the  anterior  vertical    branch  of  the 
fissure  of  Sylvius. 

2.  The   triangular  part,    sometimes  called  the  cap  of 
Broca's  convolution,  which  is  comprised  between  the  an- 
terior horizontal  branch  and  the  anterior  vertical  branch 
of  the  fissure  of  Sylvius. 

3.  The  orbital  part,  which  is  situated  below  the  anterior 

horizontal  branch  and  which  is  continuous  with  the  orbital 

• 

convolution  on  the  inferior  surface  of  the  hemisphere. 

Of  these  three  portions,  the  first  alone  is  considered 
now  to  have  any  concern  in  the  production  of  speech,  and 
when  the  unmodified  term,  Broca's  convolution,  is  used, 
this  is  the  part  that  is  referred  to.  It  is  the  part  of  the 
brain  in  which  are  stored  the  sensory  memories  (articula- 
tory-kinaesthetic)  of  a  motor  act — that  of  articulate  speech. 

The  temporal  convolutions,  of  which  there  are  also 
three — superior,  middle,  and  inferior — constitute  the  lateral 


92  The  Faculty  of  Speech, 

part  of  the  hemisphere  below  the  posterior  limb  of  the 
fissure  of  Sylvius.  The  convolution  immediately  border- 
ing the  fissure  of  Sylvius,  the  superior  temporal  convolu- 
tion, is  the  one  to  which  is  allocated  the  general  auditory 
area.  The  auditory  area  is  not  spread  over  the  entire  ex- 
ternal surface  of  the  superior  or  first  temporal  convolution  ; 
a  large  part  of  it  is  hidden  in  the  wall  of  the  fossa  of 
Sylvius,  appearing  on  the  external  surface  of  the  hemis- 
phere only  in  the  middle  and  posterior  thirds  of  the  con- 
volution. There  is  some  pathological  evidence  to  indi- 
cate that  musical  memories  have  separate  allotment  in 
the  left  superior  temporal  convolution  in  the  anterior 
part  of  the  auditory  area.1 

The  convolutions  bordering  on  the  fissure  of  Sylvius 
above  are,  after  the  inferior  frontal  convolution,  of  which 
•  we  have  already  spoken,  the  central  convolutions.  These 
have  nothing  to  do  with  the  genesis  of  speech,  but  a.11  to 
do  with  its  execution.  As  we  shall  see  later,  they  consti- 
tute almost  exclusively  the  somaesthetic  area  and  the  cor- 
tical motor  area.  Next  beyond  these,  bordering  the  Syl- 
vian  fissure,  comes  the  inferior  parietal  convolution.  It 
is  believed  that  the  higher  visual  centre  is  limited  to  the 
posterior  portion  of  the  inferior  parietal  lobule,  which  is 
known  as  the  angular  gyrus,  and  that  the  anterior  portion, 
or  supramarginal  gyrus,  has  little  or  no  function  of  stor- 
ing up  visual  images.  These  gyri,  the  inferior  frontal,  the 

1  The  only  discordant  testimony  bearing  on  localization  of  the  general 
auditory  area  is  that  of  Schafer  and  Sanger  Brown,  whose  experiments  on 
monkeys  did  not  lead  them  to  substantiate  Ferrier's  statement  that  the 
function  was  allotted  to  the  superior  temporal  convolution.  This  negative 
evidence  of  Schafer  and  Brown  should  not  be  given  the  slightest  considera- 
tion, however,  in  view  of  the  incontrovertible  pathological  testimony  at 
our  disposal,  corroborative  of  this  allocation. 


Conception  of  Aphasia.  93 

superior  temporal,  and  the  inferior  parietal,  represent  the 
confines  of  the  zone  of  language,  and  it  only  remains  nec- 
essary to  speak  of  the  relationship  of  the  primary  visual 
areas  in  the  cunei,  the  tip  of  the  occipital  lobe,  and  es- 
pecially on  its  internal  surface  immediately  around  the 
calcarine  fissure.  To  this  the  radiations  of  the  optic 
nerve  can  be  directly  traced.  In  the  chapter  on  "  Anal- 
ysis of  speech,"  I  have  said  that  the  optic  nerve  devel- 
ops its  medullary  sheath  in  the  tenth  month;  that 
before  this  time  it  can  be  distinctly  traced  as  a  bundle 
of  non-medullated  fibres,  passing  from  the  eyeballs  by 
means  of  the  optic  tract  to  the  external  geniculate  body 
and  from  there  to  the  anterior  quadrigeminal  body,  while 
another  bundle  passes  directly  into  the  optic  thalamus, 
and  fibres  go  from  the  external  geniculate  body  to  the 
thalamus  (see  Fig.  6).  The  course  of  the  optic  nerve 
from  these  ganglia  backward  is  directly  to  the  cortex  of 
the  occipital  lobes  in  the  immediate  vicinity  of  the  cal- 
carine fissure,  the  connection  being  effected  by  means  of 
the  so-called  radiations  of  Gratiolet.  In  their  course  to 
the  cuneus  the  optic  radiations  pass  immediately  sub- 
jacent to  the  angular  gyrus  and  a  lesion  in  the  latter  loca- 
tion, if  it  is  not  very  superficial,  is  apt  to  interrupt  some 
of  these  fibres.  The  pathways  leading  from  both  cunei 
to  the  left  angular  gyrus,  the  seat  of  visual  memories, 
cannot  be  traced  with  the  same  exactitude  as  the  tract  to 
the  primary  visual  areas  can  be. 

The  convolutions  that  have  thus  been  described  form 
the  anatomical  basis  of  the  zone  of  language  (see  Fig.  7), 
and  this  definite  part  of  the  brain  carries  on  the  faculty  of 
speech ;  or,  expressed  in  another  way,  the  centres  neces- 


94 


The  Faculty  of  Speech. 


sary  for  the  reception  and  interpretation  of  impulses  com- 
ing to  the  brain  bearing  on  speech,  and  for  the  emission 


PIG.  6. —Course   of  the  Optic  Fibres.     EGB,  External  i?eniculate  body  ;  AQH, 


anterior  quadrigemineal  body  ;  P of  T,  pulvinar  ;  I'C,  visual  centre  ;  If  I  C\ 


half-vision  centre. 


of  impulses  to  the  peripheral  speech  mechanism,  are  situ- 
ated in  a  definite  area  of  the  brain  cortex.  To  this  area, 
which  is  as  much  entitled  to  strict  localization  as  the 
motor  area,  the  name  zone  of  language  is  given.  Every 
one  knows  that  the^fa'culty  of  speech  is  maintained  by 


Conception  of  Aphasia.  95 

the  left  hemisphere  of  the  brain  in  those  who  are  right- 
handed,  and  by  the  right  hemisphere  in  those  who  are  left- 
handed.  And  this  for  the  same  genetic  reason  that  the 
organism  is  right-handed  in  the  majority  of  people  and 
left-handed  in  the  few;  when  the  organism  is  left-handed, 
then  the  right  hemisphere  contains  the  zone  of  language. 
It  would  seem  that  this  is  one  of  the  facts  of  physiology 
which  is  indisputable;  nevertheless,  every  now  and  then 
some  one  brings  forward  evidence  purporting  to  deny  it. 
One  of  the  most  recent  purveyors  of  such  evidence  is  Molt- 
schanow, '  of  Moscow,  who  in  relating  a  case  says  that  his 
observations  were  confirmed  by  Rossolimo.  He  cites  the 
following  instance  in  support  of  the  claim  that  the  speech 
area  is  not  always  on  the  left  side  of  the  brain  when  the 
organism  is  right-handed :  A  man  fifty-six  years  of  age, 
of  alcoholic  habits,  had  a  stroke  of  apoplexy,  followed 
by  disturbance  of  speech  two  years  before  his  entrance  to 
the  hospital,  when  the  author  discovered  sharply  defined 
"amnesic  aphasia"  with  word  deafness  and  total  left-side 
hemiplegia.  Recognizing  that  such  an  unusual  combina- 
tion as  left-side  hemiplegia  and  aphasia  probably  bespoke 
a  left-handed  man,  the  author  questioned  the  patient's 
wife  on  many  occasions  to  learn  if  the  patient  used  the 
left  hand  by  preference,  but  she  insisted  that  he  was 
right  -  handed.  At  the  autopsy  there  were  found  t\vo 
areas  of  softening  in  the  right  hemisphere,  one  in  the 
posterior  segment  of  the  first  temporal  gyrus,  the  second 
in  the  posterior  portion  of  the  third  frontal  gyrus.  Noth- 
ing abnormal  was  found  in  the  left  hemisphere.  The 

1  Moltschanovv  :  "  Zur  Frage  von  der  Localisation  des  Sprachcentrums." 
Xeurologisches  Centralblatt,  1893,  p.  673. 


96  The  Faculty  of  Speech. 

writer  says  that  this  case  speaks  unequivocally  against 
what  he  is  pleased  to  call  Broca's  dictum  concerning  the 
location  of  the  speech  area.  He  says  further  that  other 
authors  have  probably  had  similar  cases,  for  in  looking 
over  the  literature  of  aphasia  he  had  noted  that  it  is 
oftentimes  impossible  to  determine  from  the  reported 
cases  whether  the  patient  was  right-handed  or  left.  This 
point  the  writer  need  have  no  difficulty,  I  believe,  in  de- 
termining in  the  future.  If  the  patient  whose  history  he 
reads  has  a  left  hemiplegia  with  aphasia,  that  patient  is 
a  right-handed  man,  and  vice  versa.  It  is  almost  incredi- 
ble that  physicians  will  attempt  to  convince  themselves 
that  evidence  of  this  kind  can  have  the  slightest  effect 
in  overthrowing  such  an  invariable  rule  as  the  one  relat- 
ing to  the  location  of  the  speech  area,  just  cited.  An 
attempt  to  discredit  a  law  so  firmly  established  as  this 
by  the  citation  of  testimony  of  a  woman  concerning  the 
right-handedness  or  left-handedness  of  her  husband  is 
like  trying  to  trip  up  Atlas  by  putting  a  microbe  to  ob- 
struct his  path.  How  is  any  one  to  know  that  I  as  an 
organism  am  left-handed  ?  I  write  with  the  right  hand  ; 
with  it  I  throw,  I  use  a  knife  to  whittle;  I  have  used  it 
in  the  past  to  operate ;  in  fact,  every  ordinary  and  extra- 
ordinary act  calling  for  dexterity  is  performed  sccnndnm 
artem  with  the  right  hand.  Yet  I  am  left-handed  in  the 
sense  of  the  term  that  originally  the  organism  was  in- 
tended to  be  served  particularly  by  that  hand,  and  were 
it  not  for  the  care  taken  in  the  nursery  the  left  hand 
would  be  the  dextrous  member  to-day.  Therefore,  it 
seems  to  me  that  unless  those  who  come  in  the  most  in- 
timate contact  with  me  are  informed  to  the  contrary,  I 


Conception  of  Aphasia.  97 

should  be  considered  a  right-handed  individual.  And 
yet,  no  one,  I  think,  would  deny  that,  if  such  a  person 
were  to  have  a  lesion  on  the  right  side  of  his  brain  in- 
volving the  areas  to  which  are  allocated  the  functions  of 
speech,  he  would  have  with  it  aphasia. 

The  determining  causes  of  right-handedness  is  a  prob- 
lem in  biology  that  I  can  refer  to  only  very  briefly.  It 
is  an  extremely  important  one,  because  no  one  now  doubts 
that  dextrality  is  conditioned  by  the  same  factors  that  de- 
termine the  unilaterality  of  executive-speech  representa- 
tion, and  that  the  former  is  an  evolutionary  differentiation 
of  the  latter.  It  has  been  considered  to  be  dependent 
upon  tribal  and  social  customs  originally,  and  as  an  in- 
herited characteristic.  The  most  fanciful  theories  as  well 
as  the  most  careful  scientific  experiments  have  been  under- 
taken to  explain  it.  Of  the  former  the  one  that  crops  up 
most  irrepressibly  in  popular  and  in  scientific  literature  is 
that  right-handedness  has  to  do  with  the  way  in  which  the 
child  is  held  in  its  waking  hours  and  the  side  on  which 
it  lies  while  it  sleeps.  This  can  be  refuted  so  easily  that 
it  is  scarcely  worth  the  doing.  If  a  child  becomes  right- 
handed  because  the  nurse  carries  it  so  that  the  left  arm  is 
hampered  from  free  movement,  then  left-handed  nurses 
(who  naturally  carry  their  charges  on  the  left  arm  and 
therefore  keep  the  child's  right  arm  close  to  them)  could 
always  be  depended  upon  to  bring  up  left-handed  children ; 
but  as  a  matter  of  fact  they  cannot  be.  Among  the  seri- 
ous theories  that  have  been  propounded  for  its  explanation 
a  few  deserve  specific  mention.  Ogle  suggested  that  it 
was  conditioned  by  peculiarities  in  the  mode  of  origin  and 
distribution  of  the  left  internal  carotid  artery,  and  Bastian 


98  The  Faculty  of  Speech. 

pointed  out  that  right-handedness,  or  the  conditions  that 
determine  it,  has  a  definite  relationship  to  the  increased 
specific  weight  of  the  cortical  gray  matter  of  the  left 
hemisphere  and  to  greater  convolutional  complexity.  Both 
of  these  conditions  may  be  the  consequence  and  not  the 
cause  of  dextrality.  Recently  Baldwin  has  propounded  a 
theory,  based  on  careful  and  intelligent  observation  of  his 
own  child,  that  right-handedness  is  a  manifestation  of  brain 
variation  utilized  for  expansion  which  develops  further  into 
speech ;  that  it  is  due  to  differences  in  the  two  half-brains 
reached  at  an  early  stage  in  life  and  that  the  promise  of  it 
is  inherited. 

^J,t  has  been  proven  beyond  cavil  that  destruction  of  the 
foot  of  the  third  frontal  convolution  causes  inability  to  ar- 
ticulate words ;  that  destruction  of  the  superior  temporal 
gyrus  causes  inability  to  understand  spoken  words,  and  a 
lesion  in  the  inferior  parietal  gyrus  causes  inability  to  in- 
terpret words  which  can  be  seen.  These  are  the  three 
components  that  enter  into  the  constitution  of  speech,  and 
they  are  the  three  factors  that  are  absolutely  essential  to 
the  production  of  perfect  speech.  The  convolutions  of 
the  brain  in  which  they  are  situated  are  immediately  ad- 
jacent to  each  other.  They  are  intimately  connected  by 
means  of  annectant  convolutions,  the  most  important  of 
which  are  the  insular  gyri,  and  by  association  tracts  to 
be  named  presently.  These  convolutions  border  on  the 
Sylvian  fissure,  and  they  are  all  supplied  by  branches  of 
one  blood-vessel,  the  middle  cerebral  or  Sylvian  artery,  the 
direct  continuation  of  the  internal  carotid  artery. 

The  area  thus  mapped  out  is  in  shape  somewhat  like  a 
gondola;  the  bottom  being  formed  by  the  superior  tern- 


Conception  of  Aphasia. 


99 


poral  gyrus,  the  upturned  hind  end  by  the  angular  and 
supramarginal  gyri,  the  front  end,  which  does  not  rise 
so  high  as  the  other  end,  by  the  frontal  operculum,  the  in- 
ferior end  or  foot  of  the  third  frontal  convolution  (Fig. 
7).  This  area  is  not  entirely  occupied  by  the  speech 
centres,  by  which  is  meant  portions  of  the  cortex  in  which 
are  stored  the  visual,  auditory,  and  kinaesthetic  articula- 


FlG.  7.— Zone  of  Language  ;  Position  of  Centres. 

tory  memories.  These  centres,  the  storehouses  of  such 
memories,  are  narrowly  confined  (though  not  sharply  de- 
limited, in  all  probability),  and  the  remainder  of  the  zone 
of  language,  that  is,  the  area  between  the  centres,  is  con- 
stituted by  association  tracts  or  pathways  connecting  these 
centres. 

The  association  or  connecting  pathways  of  the  brain 
must  now  be  discussed.  It  is  weil  known  that  the  nerve 
fibres  of  the  brain  are  divided  into  three  groups  : 

i.   Commissural  fibres,  which  unite  symmetrical  points 


ioo  The  Faculty  of  Speech. 

in  the  two  cerebral  hemispheres.  These  constitute  the 
corpus  callosum  and  the  anterior  white  commissure  or 
psalterium.  They  need  not  further  concern  us  here. 

2.  The  fibres  of  association  ;  long  and  short  fibres  which 
unite  different  points  in  the  same  cerebral  hemisphere. 

3.  Projection  fibres ;  fibres  that  unite  the  cortical  gray 
matter  of  a  hemisphere  with   the  gray  substance  of  the 
brain  stem  and  cerebro-spinal  axis. 

The  association  fibres  of  the  brain  are  divided  into  the 
long  and  short  fibres.  The  short  fibres  unite  points  in 
the  cerebral  hemisphere  that  are  more  or  less  adjacent, 
and  they  are  found  immediately  beneath  the  cortical  gray 
matter.  The  long  fibres,  on  the  other  hand,  unite  distant 
parts  of  a  hemisphere,  and  they  are  situated  at  some  depth 
from  the  cortex.  They  are  described  as  the  (a)  superior 
longitudinal  fascicle,  which  unites  the  gray  matter  of  the 
frontal  lobe  with  the  gray  matter  of  the  occipital  and  the 
temporal  lobes ;  (b}  the  inferior  longitudinal  fascicle,  made 
up  of  fibres  that  unite  the  occipital  lobe  and  the  tip  of  the 
temporal  lobe  ;  (c)  the  arciform  fascicle  or  cingulum,  which 
is  made  up  of  fibres  going  in  an  antero-posterior  direction 
from  the  frontal  to  the  temporal  lobe  (the  fascicle  gets 
its  name  from  the  fact  that  it  bends  to  conform  to  the 
corpus  callosum) ;  (d}  the  uncinate  fascicle,  which  connects 
the  inferior  frontal  convolution  with  the  tip  of  the  tem- 
poral lobe  immediately  beneath  the  fissure  of  Sylvius. 
These  association  fibres,  which  are  formed  by  the  axones 
of  the  pyramidal  cells  in  the  cerebral  cortex  or  their  col- 
lateral branches,  are  shown  graphically  by  the  following 
diagram  (Fig.  8),  which,  if  contrasted  with  the  diagram 
showing  the  zone  of  language,  will  represent  graphically 


Conception  of  Aphasia.  101 

the    avenues    of    connection    between    the    three    speech 
centres. 

All  text-books  on  the  anatomy  of  the  brain,  with  the 
one  exception  of  Van  Gehuchten's,  describe  under  the  name 
of  the  cortico-protuberantial  fascicle  a  bundle  of  nerve 
fibres  which  unites  the  cerebral  cortex  of  the  frontal  lobe 
and  of  the  occipital  lobe  with  the  gray  masses  constituting 
the  nuclei  of  the  pons.  But  the  recent  researches  of  De- 
jerine  and  of  Flechsig  have  proven  that  the  cortico-protu- 


FlG.  8.— Association  Fibres. 

berantial  fibres,  instead  of  arising  from  the  cortical  sub- 
stance of  the  frontal  and  of  the  occipito-temporal  lobes, 
arise  entirely  from  the  gray  masses  which  constitute-  the 
central  convolutions,  and  the  latter  contends  that  no 
fibres  from  other  parts  of  the  cortex  than  those  of  the 
central  lobe  enter  into  the  constitution  of  the  pyramidal 
tracts.  The  extremely  important  bearing  of  this  on  our 
conception  of  aphasia  will  be  seen  later  on.  A  second 
fact  of  not  much  less  importance  than  the  first,  but  one 
that  is  less  generally  accepted,  is  that  heretofore  it  has 
been  held  by  many  authors  that  every  region  of  the  cere- 


IO2  The  Faculty  of  Speech. 

bral  cortex  in  man  was  in  connection  with  the  inferior 
gray  masses  by  fascicles  of  nerve  fibres  that  were  desig- 
nated projection  fibres. 

Even  so  recent  a  writer  on  the  subject  of  aphasia  as 
Mirallie  has  described  the  inferior  pediculo-frontal  fasci- 
cle, which  is  considered  by  Pitres,  by  Raymond,  by  Bris- 
saud,  and  by  others  to  be  of  such  paramount  importance  in 
explaining  the  symptomatology  of  motor  aphasia.  But  to- 
day, in  the  light  of  the  evidence  furnished  by  Flechsig  and 
upheld  by  such  a  brilliant  and  trustworthy  anatomist  as 
Van  Gehuchten,  the  inferior  pediculo-frontal  fascicle  must 
go,  and  with  it  the  idea  that  the  projection  tracts  arise  from 
all  or  indefinite  parts  of  the  brain.  It  remained  for  Flech- 
sig to  prove,  as  he  has  done  to  the  satisfaction  of  some 
neuropathologists,  although  not  to  that  of  others  (Deje- 
rine),  that  the  projection  fibres  exist  only  fora  third  of  the 
entire  cerebral  cortex,  and  that  two-thirds  of  the  cortex  of 
the  human  brain  has  no  connection  whatsoever  with  the 
inferior  nerve  centres'. 

Flechsig  has  shown  in  his  study  of  the  embryonal  and 
the  postnatal  cerebrum  that  the  sensory  paths  are  the 
ones  which  first  become  medullated.  And  of  these  sen- 
sory- paths  the  first  to  ripen  is  that  concerned  in  the 
sense  of  smell,  and  the  last  that  which  carries  auditory 
impulses.  By^following  these  sensory  paths  to  the  cortex 
he  has  shown  that  the  latter  may  be  divided  into  four  areas 
or  spheres,  to  be  enumerated  presently.  I  shall  make  a 
somewhat  detailed  review  of  the  recent  statements  of 
Flechsig  regarding  the  localization  of  function  in  the 
cortical  area.  This  author  has  divided  the  cortex,  first  of 
all,  into  two  very  distinct  zones,  the  zone  of  the  centres 


Conception  of  Aphasia. 


10 


of  projection,  or  the  sensory  spheres,  which  take  up  about 
one-third  of  the  whole  cortical  area ;  and  the  remainder  of 
the  cortex,  which  is  devoid  of  fibres  of  projection,  but 
which  is  united  to  the  other  sensory  spheres  by  innu- 
merable fibres  of  association,  and  to  which  are  given  the 
names  of  zones  or  centres  of  association. 


The  zones  or  centres  of  projection  comprise,  according 
to  Flechsig,  four  sensorial  spheres  (Figs.  9  and  10) : 

i.  The  tactile  sphere,  or  somcestlietic  area.  It  occupies 
the  entire  region  between  the  fossa  Sylvii  up  to  the  corpus 
callosum,  and  includes  the  central  convolutions,  the  para- 
central  lobule  and  the  posterior  part  of  the  three  frontal 
convolutions,  and  the  midde  third  of  the  gyrus  fornicatus. 


10.1 


The  Faculty  of  Spcecli. 


This  zone  represents  the  cortical  field  in  which  terminate 
on  either  side  the  fibres  of  the  median  fillet  which  do  not 
stop  at  the  basal  ganglia.  These  fibres  carry  into  the 
cortex  the  impulses  that  are  concerned  in  sensations  of 
touch,  pain,  temperature,  muscle  and  tendon  sense,  thirst, 
sexual  sensations,  and  in  short,  all  the  sensations  that 


FIG.  io.— Internal  Surface  of  Brain,  after  Flechsig.  A.  Somzesthetic  area; 
/?,  parietal  association  centre  ;  C,  visual  area  ;  D,  occipito-temporal  associa- 
tion centre  ;  £,  gyrus  hippocampus  ;  7-",  olfactory  area  ;  G,  frontal  association 
centre. 

arise  from  within  the  body  and  inform  us  as  to  the  condi- 
tion of  the  body.  Therefore  the  name,  somaesthetic  area. 
This  is  the  area  in  which  are  mirrored  bodily  sensations. 
In  addition  to  being  a  sensory  field,  this  area  is  also  the 
great  motor  region  from  which  nearly  all  the  movements 
serving  for  the  voluntary  satisfaction  of  the  bodily  feel- 
ings and  instincts  seem  to  start.  It  is  the  area  from 
which  the  impulse  starts  when  a  person  voluntarily 


Conception  of  Aphasia.  105 

breathes,  speaks,  swallows,  chews,  or  does  any  purpos- 
ive movement.  The  cells  of  origin  of  the  fibres  conduct- 
ing these  impulses  are  analogous  to  the  giant  pyramidal 
cells  of  the  ventral  horns  of  the  spinal  cord ;  the  axones 
of  these  cells  constitute  the  frontal  cortico-protuberantial 
fascicle  of  Flechsig. 

2.  The  olfactory  spJicrc.     This  sphere  is  limited  t:>  the 
olfactory  trigone  and  the  adjacent  part  of  the  convolution 
of  the  corpus  callosum,  the  anterior  perforated  space,  the 
uncinate  gyrus,  which   is   in  contact  with    the   island   of 
Reil,  and  the  adjacent  parts  of  the  hippocampus. 

3.  The  visual  sphere.       This  is  situated  on  the  internal 
surface  of  each    cerebral    hemisphere,  in   the   immediate 
neighborhood  of  the  calcarine  fissure,  and  fibres  run  from 
this  tract  into  those  adjacent  areas  of  the  occipital  cortex 
which  show  the  macroscopic  stripe  of  Vicq  d'Azyr.     The 
centripetal  fibres  of  the  visual  sphere  come  from  the  optic 
thalamus,  the  external  geniculate   body,  and  the  anterior 
quadrigeminal    body.      Among    these    centripetal    fibres, 
those  that   come  from  the  external  geniculate  body  ter- 
minate exclusively  in  the  borders    of   the  calcarine  fis- 
sure, while  those  coming  from  the  optic  thalamus  and  the 
quadrigeminal    tubercles    terminate   around    this    fissure. 
This  distinction,  according  to  Flechsig,  is  important,  be- 
cause the  external  geniculate  bodies  receive  exclusively 
the  fibres  coming  from  the  macula  lutea. 

4.  The   auditory   sphere.       The    fibres    communicating 
auditory  impulses  to  the  cerebral  cortex  form  the  lateral 
fillet  in  the  pons  and  are  connected  largely  with  the  me- 
dian geniculate  body.     They  terminate  in  the  transverse 
temporal  gyri,  especially  in  the  anterior  one.     This  sphere 


io6  The  Faculty  of  Speech. 

is  united  by  centripetal  fibres  to  the  inferior  quadrigemi- 
nal  body  and  to  the  internal  geniculate  body,  and  by 
centrifugal  fibres  (the  temporal  cortico-protuberantial  fas- 
cicle) with  the  nucleus  of  the  pons.  Flechsig  con- 
siders these  descending  fibres  as  a  motor  pathway  which 
has  for  its  function  the  transmission  of  impulses  ar- 
riving in  the  auditory  sphere  from  the  muscles  that  move 
the  ear. 

In  addition  to  these  projection  fibres  uniting  the  sen- 
sory spheres  with  the  inferior  gray  masses  of  the  brain 
axis,  there  exists  in  each  centre  of  projection  a  number 
of  fascicles,  composed  of  centripetal  and  centrifugal  fibres, 
uniting  the  centre  with  the  corresponding  part  of  the 
thalamus. 

These  centres  of  projection  are  in  connection  with  all 
the  peripheral  organs  by  a  double  set  of  nerve  fibres,  one 
the  ascending  or  centripetal  fibres,  which  are  sensory,  the 
other  a  descending  centrifugal  set  of  fibres,  which  are  mo- 
tor. These  two  sets  of  fibres  end  in  the  same  cortical 
region.  According  to  this  there  is  no  exclusively  motor 
cortex,  no  exclusively  sensory.  The  sensory  spheres  are 
thus  in  reality  the  sensori-motor  regions  of  the  cerebral 
cortex.  All  the  impressions  received  by  the  terminals  of 
the  peripheral  nerves  and  their  sensory  fibres  are  con- 
ducted to  the  tactile  sphere  of  the  cerebral  cortex  by 
a  series  of  centripetal  neurons.  These  impressions  are 
transmitted  to  the  cells  of  origin  of  the  descending  or 
motor  fibres  of  this  same  region,  which  then  descend  by 
a  series  of  centrifugal  neurons  as  far  as  the  peripheral 
muscles.  It  is  the  same  for  the  olfactory  impressions,  the 
visual,  and  the  acoustic.  They  are  transmitted  by  the 


Conception  of  Aphasia.  107 

centripetal  pathways  to  the  corresponding  sensory  spheres. 
The  centres  of  projection,  considered  by  themselves,  are 
completely  separated  from  the  centres  of  association  which 
surround  them,  and  constitute  thus  a  sort  of  nervous 
centre  for  reflexes  of  cortical  origin. 

When  these  centres  have  become  ripe,  that  is,  when 
the  fibres  going  to  them  and  coming  from  them  are 
medullated,  only  about  one-third  of  the  whole  area  of  the 
cortex  has  been  disposed  of.  Two-thirds  of  the  cortex 
appears  to  have  nothing  to  do  with  the  periphery,  but  is 
reserved  for  other  and  apparently  higher  work.  These 
areas  are  the  so-called  association  centres  of  Flechsig. 
Before  considering  them  it  is  well  to  draw  attention  to 
two  statements  of  Flechsig  regarding  the  projection 
areas. 

The  somaesthetic  area  is  much  more  extensive  than  are  all 
the  other  areas  combined.  This  disproportion  should  not 
be  a  matter  of  surprise.  In  it  are  represented  all  the  forms 
of  tactile  excitation  that  acquaint  us  with  the  outer  world, 
and  from  it  start  all  impulses  by  which  are  externalized 
thought,  feelings,  desires.  The  olfactory  sphere  is  very 
little  developed,  because  the  sense  of  smell  is  so  rudi- 
mentary. The  auditory  sphere  and  the  visual  sphere  re- 
produce in  the  brain,  the  one  the  sensitive  surface  of  the 
organ  of  Corti  of  the  internal  ear,  and  the  other  the  retina. 
These  last  three  spheres  inform  us  of  the  external  world 
and  are  dependent  for  their  activity  on  sensation  coming 
from  without.  The  second  point  made  by  Flechsig  is 
that  the  sensory  spheres  are  localized  around  the  primary 
fissures,  the  visual  sphere  around  the  calcarine  fissure,  the 
tactile  sphere  around  the  central  fissure,  the  olfactory 


io8  The  Faculty  of  Speech. 

sphere  and  the  auditory  sphere  around  the  fissure  of 
Sylvius. 

The  zone  of  the  association  centres  is  formed  of  three 
distinct  centres  :  first,  the  posterior  large  association  centre, 
which  comprises  a  part  of  the  lingual  convolution,  the 
fusiform  convolution,  all  of  the  parietal  convolutions,  the 
inferior  temporal  convolution,  and  the  anterior  part  of 
the  external  surface  of  the  occipital  lobe ;  second,  the 
median  association  centre,  which  corresponds  to  the 
island  of  Reil ;  third,  the  anterior  association  centre, 
which  is  constituted  by  a  portion  of  the  superior  frontal 
convolution  and  a  large  part  of  the  median  and  third 
frontal  convolutions.  Flechsig  believes  that  these  asso- 
ciation centres  represent  arrangements  which  unite  the 
activities  of  the  central  internal  sense  organs  and  build 
them  up  to  higher  limits.  Sensory  impressions  of  differ- 
ent qualities,  visual,  auditory,  tactile,  olfactory,  and  gus- 
tatory, are  united,  or,  at  any  rate,  the  anatomical  mecha- 
nism is  afforded  for  their  union.  These  association  centres 
are  completely  independent  of  the  inferior  gray  masses, 
and  are  the  portions  of  the  cerebral  cortex  which  above 
all  others  are  concerned  in  the  higher  intellectual  mani- 
festations, judgment,  memory,  etc. 

The  middle  association  centre  is  represented  by  the 
cortex  of  the  island  of  Reil.  This  is  the  centre  which 
unites  all  the  convolutional  areas  bordering  the  fossa  of 
Sylvius,  the  integrity  of  which  is  indispensable  for  the 
preservation  of  language.  It  belongs  in  part  to  the  som- 
jesthetic  area  (especially  to  the  region  for  the  speech 
organs),  partly  to  the  auditory  area,  and  partly  to  the  ol- 
factory area.  The  large  posterior  centre  of  association  is 


Conception  of  Aphasia.  109 

the  part  of  the  cortex  which  puts  us  en  rapport  with  the 
external  world.  It  is  that  which  unites  the  superior  cen- 
tres for  all  the  sensations,  tactile,  visual,  and  acoustic,  that 
come  to  us  from  without. 

Flechsig  points  out  that  the  association  areas,  the  con- 
volutions which  have  no  direct  communication  with  the 
crus,  central  ganglia,  or  the  corpus  callosum,  are  those 
which  are  latest  in  the  order  of  development,  and  on  this 
ground  alone  might  be  supposed  to  be  concerned  in  more 
strictly  mental  faculties,  which  are  latest  in  their  mani- 
festations. These  areas  constitute  a  striking  difference 
between  the  human  cerebrum  and  that  of  lower  animals. 
The  centres  of  projection  exist  in  the  lower  animals  to 
a  very  much  more  highly  developed  extent  than  in  man. 
But  in  man,  on  the  other  hand,  the  centres  of  associa- 
tion are  immeasurably  greater,  while  as  we  descend  the 
scale  of  animal  life  the  centres  of  association  become 
fewer  and  finally  disappear.  It  has  been  noted  that  the 
centres  of  association  are  often  interpolated  between  the 
centres  of  projection,  so  as  to  separate  these  last  centres 
completely  one  from  another.  It  would  seem  to  be  in 
accord  with  the  general  plan  of  construction  of  the 
nervous  system  and  with  what  we  know  of  mental 
operations,  that  these  convolutions  which  are  withdrawn, 
so  to  speak,  from  direct  relation  with  the  outer  world 
should  be  the  seat  of  the  more  purely  intellectual 
operations. 

From  a  consideration  of  the  morbid  anatomy  of  some 
cerebral  diseases,  especially  general  paresis,  Flechsig  has 
come  to  the  conclusion  that  the  anterior  association  centre 
is  the  part  that  conditions  consciousness  of  personality 


1 10  The  Faculty  of  Speech. 

(Personlichkeitsbewusstsein).  Lesion  of  this  area  causes, 
in  a  word,  loss  of  the  faculty  of  abstraction. 

This  extensive  reference  to  the  view  of-  Flechsig  has 
seemed  to  me  fitting  not  only  because  it  is  a  most  im- 
portant advance  in  the  interpretation  of  the  physiology 
of  the  brain,  but  also  because  it  is  of  direct  and  signal 
service  in  the  conception  of  aphasia  as  here  outlined, 
although  it  is  not  in  entire  harmony  with  it.  More- 
over, it  has  a  direct  bearing  on  many  problems  in  the 
morbid  physiology  of  the  brain  that  confront  the  physi- 
cian to-day.  In  a  way,  Flechsig's  contentions  are  not  at 
all  new.  Views  very  similar-  to  them  were  expounded  by 
Broadbent  nearly  twenty-five  years  ago,  when  he  pointed 
out  that  the  centres  which  Flechsig  calls  "  association 
centres"  were  parts  of  the  cortex  that  were  neither  in 
direct  relation  with  peduncular  fibres  nor  with  those  of 
the  corpus  callosum.  These  association  areas  are  also 
in  reality  what  Bastian  has  described  as  "  annexes  of  the 
perceptive  centres." 

Some  of  Flechsig's  views,  it  seems  to  me,  will  be  very 
slowly  accepted,  particularly  those  referable  to  the  projec- 
tion systems  of  fibres.  Already  Monakow  and  Kolliker 
have  taken  serious  exception  to  a  number  of  his  conten- 
tions and  very  recently  Dejerine  contests  them. 

e  of  Language  —  Site   of  the   Revival  of    Words    in 
Silent  Thought. 

The  zone  of  language  is  a  part  of  the  brain  in  which 
are  carried  on  the  processes  essential  to  the  facultas  syna- 
trix.  It  is  that  part  of  the  brain  whose  function  is  the 


Conception  of  Aphasia.  \  \  \ 

necessary  material  substrate  of  conception  and  of  com 
prehension  and  expression. 

By  way  of  introduction,  it  may  be  said  that  when  the 
expression  "zone  of  language"  is  used  I  do  not  mean 
an  area  which  can  be  mapped  out  on  the  surface  of  the 
brain  by  unvarying  mathematical  lines.  Rather  than  have 
such  interpretation  put  upon  the  use  of  the  term,  I  should 
prefer  to  be  understood  to  use  it  merely  as  an  expression 
of  convenience. 

This  speech  area  or  zone  of  language  is  not,  in  all  prob- 
ability, strictly  delimited.  It  varies  in  individual  cases, 
and  at  different  periods  of  life  in  the  same  individual,  i.e., 
it  is  subject  to  phylogenetic  variation  and  to  ontogenetic 
variation  as  well ;  the  latter  depending  somewhat  on  the 
speech  acquisition  of  the  individual,  arid  on  the  range  and 
number  of  avenues  by  which  he  receives  or  has  schooled 
himself  to  receive  information  of  objects.  This  area  is 
a  receptive  and  an  emissive  centre  for  all  forms  of  stimuli 
or  excitations  that  reach  it,  and  which  its  individual  de- 
velopmental metamorphosis  has  accustomed  it  to  accept,  to 
give  tenancy  to,  and  to  elaborate  into  new  forms  of  stim- 
ulation. It  is  receptive  chiefly  to  auditory  and  visual 
stimuli,  which  it  emits  to  other  centres,  and  also  to  kinaes- 
thetic,  olfactory,  and  gustatory  stimuli.  It  is  emissive 
to  the  frontal  lobes  and  to  the  cortex  of  the  Rolandic 
region,  from  which  start  the  motor  projection  tracts  and 
by  which  all  thought  externalization  is  mediated. 

The  speech  area  or  zone  of  language  is  an  area  made 
up  of  neurons,  some  of  which  send  their  axones  into  the 
Rolandic  region  and  into  the  frontal  regions  of  the  brain, 
while  others  confine  their  distribution  to  the  speech  area 


i  1 2  The  Faculty  of  Speech. 

itself,  and,  as  they  do  not  pass  outside  of  this  area,  they 
may  be  looked  upon  as  intercentral  neurons. 

The  zone  of  language  has  no  projection  fibres  going 
directly  into  the  motor  projection  tract ;  it  sends  no  im- 
pulses directly  to  the  projection  tract  which  carries  down 
neural  impulses  to  be  externalized  as  speech.  On  the 
contrary,  the  zone  of  language  sends  impulses  composed, 
in  the  illiterate,  of  auditory  and  articulatory  memories  of 
the  word,  and,  in  the  educated,  of  auditory,  visual,  and  ar- 
ticulatory memories,  to  the  Rolandic  cortex  and  to  partic- 
ular areas  of  this  region,  depending  on  the  manner  in 
which  the  idea  is  to  be  externalized;  that  is,  whether  by 
spoken  or  written  word  or  symbol,  or  by  some  form  of 
mimetic  or  purposive  action,  which  the  judgment  of  the 
individual  decides  to  be  most  serviceable  in  conveying 
the  thought.  If  the  idea  is  to  be  expressed  by  articulate 
speech,  the  impulses  are  sent  to  that  area  of  the  Rolandic 
region  in  which  there  is  separate  allocation  for  the  move- 
ments of  respiration,  vocalization,  lingual  and  labial  ac- 
tion. This  area  is  in  the  foot  of  the  ascending  central 
convolution,  adjacent  to  the  area  in  which  are  stored  sen- 
sory memories  of  articulatory  movements,  Broca's  area. 
From  here  the  real  motor  impulses  start.  They  go  down 
through  the  motor  projection  tract,  the  axones  of  which 
en  masse  form  the  pyramidal  tract,  and  the  central  motor 
projections  of  the  cranial  nerves,  to  the  various  muscles 
whose  contraction  produces  articulate  speech.  There  is 
reason  to  believe  that  these  outgoing  impulses  are  co- 
ordinated, given  rhythm,  force,  and  association,  not 
in  the  cortex  of  the  brain,  but  in  stations  situated  in 
the  brain  ganglia,  the  cerebellum,  and  the  pons-ob- 


Conception  of  Aphasia,  113 

longata,    the    centres    composing    these    stations    acting 
automatically. 

When  the  idea  is  externalized  in  writing,  in  complex 
movements  such  as  mimetic  movements,  or  by  a  simple 
nod  of  negation  or  affirmation,  a  simple  movement  of 
beckoning,  the  genesis  of  the  symbol  or  the  pantomime 
is  exactly  analogous  to  that  of  articulate  speech.  They 
are  all  the  result  of  internal  language,  and  the  person 
who  writes  an  impassioned  editorial  on  some  subject  that 
fires  his  patriotic  spirit  is  as  cognizant  of  the  words 
ringing  within  him  as  the  orator  who  enunciates  them 
from  the  platform.  The  preparation  of  the  language 
and  the  words  is  in  both  cases  the  same.  They  both  re- 
quire the  absolute  integrity  of  the  zone  of  language,  the 
only  difference  being  that  in  the  second  instance  the  fin- 
ished product  is  sent  to  the  cortical  area  which  is  the  cen- 
tre of  the  articulo-vocal  musculature,  and  in  the  other  to 
the  Rolandic  allocation  of  a  much  less  complex  motor 
mechanism,  namely,  to  the  cortical  centre  of  the  member 
that  holds  the  pen,  whether  that  member  be  the  hand  or 
other  mobile  part  of  the  body.  In  the  case  of  the  speaker, 
the  primary  revival  is  in  the  auditory  centre,  and  this  in- 
fluences to  activity  both  of  the  other  speech  centres — the 
articulatory-kinaesthetic  centre  strongly,  the  visual  centre 
slightly — and  the  perfected  word  is  externalized  by  the 
articulatory  area/  o£  ihe  Rolandic  cortex.1  In  the  case  of 
a  writer,  it  is  probable  that  the  visual  centre  is  the  seat 
of  primary  revival  of  the  word,  but  it  may  be  quite  as  le- 

1  Some  students  of  language  believe  that  the  primary  revival  of  word 
images  in  the  case  of  the  speaker  is  in  the  kinresthetic  articulatory  centre, 
but  I  hold  to  the  view  as  stated  above. 


ii4  The  Faculty  of  Speech. 

gitimately  explained  by  considering  that  this  takes  place 
in  the  auditory  area.  The  visual  centre  being  then  thrown 
into  a  state  of  vigorous  activity,  the  articulatory-kinaes- 
thetic  influenced  very  mildly,  the  finished  product  is  sent 
to  and  executed  by  the  arm  area  of  the  Rolanclic  cortex. 
The  direct  association  that  may  take  place  between  the 
primary  revival  of  auditory  word  images  and  the  produc- 
tion of  written  symbols  is  seen  in  those  rare  cases  of  chil- 
dren born  blind,  who  afterwards  learn  to  write.  As 
a  rule,  the  visual  centre  conditions  writing,  both  in  its 
development  and  in  its  production. 

The  action  may  be  compared  to  that  of  a  corporation 
which  is  accustomed  to  send  simple  commissions  to  one 
broker  for  execution,  while  other  more  complicated  com- 
missions, requiring  the  concerted  action  of  a  number  of 
people,  are  sent  to  a  firm  having  facilities  for  the  execution 
of  such  orders,  who  have  accustomed  themselves  to  such 
responsibilities.  The  first  broker  may  execute  offer- 
ings in  a  way  very  similar  to  the  second,  but  his  transac- 
tion is  done  in  a  different  place  and  requires  little  or  no 
concerted  action,  while  the  transaction  of  the  latter  is  so 
complex  that  it  requires  the  associate  action  of  a  number  of 
individuals  in  different  locations,  perhaps  in  different  cities. 

It  is  the  same  way  in  pantomime.  Every  one  has  felt 
the  intensity  with  which  some  simple  command,  such  as 
"  Come  back !"  "  Get  out !"  and  the  like,  has  been  formed 
in  internal  speech  on  occasions  when  necessity  or  circum- 
stance compelled  communication  by  signs.  In  such  an 
instance  the  words  are  fully  formed  in  the  zone  of  lan- 
guage; we  are  cognizant  of  internal  language,  but  our 
judgment  informs  us  that  it  is  wiser  to  attempt  to  sum- 


Conception  of  Aphasia.  115 

mon  to  us  a  person  who  is  beyond  the  reach  of  the  voice 
by  motioning  of  the  hands  or  arms  than  by  shouting.  In 
such  a  case  internal  speech,  though  fully  formed  by  the 
activity  of  centres  in  the  zone  of  language,  is  externalized 
by  a  wave  of  the  hand,  the  motor  impulse  of  which  starts 
from  that  portion  of  the  cortex  known  as  the  arm-hand 
centre,  and  which  is  externalized  by  simple  muscular 
movements. 

All  thought  or  ideas  are  revealed  through  words,  acts, 
and  deeds,  all  of  which  are  the  immediate  result  of  mus- 
cular action.  This  action  is  conditioned  by  influences 
operative  on  the  Roland ic  cortical  area,  for  it  is  there  and 
there  alone  that  movements  having  differentiated  func- 
tions have  representation.  It  should  be  said  here  that 
this  is  in  apparent  contradiction  to  the  claims  of  some 
experimentalists  who  teach  that  by  excitation  of  the  su- 
perior temporal  convolution  there  results  contraction  of 
the  musculature  of  the.  ear,  and  by  excitation  of  the  oc- 
cipital cortex  there  follows  movement  of  the  eyeballs.  It 
is  by  no  means  so  on  closer  examination,  and  the  theory 
here  suggested  explains  more  logically  than  does  any  other 
the  slight  muscular  activity  that  results  from  such  excita- 
tion. All  the  special  senses  are  provided  with  a  highly 
developed  muscular  mechanism  whose  function  is  to  fa- 
cilitate the  action  of  the  special  sense  and  to  contribute  to 
its  perfection.  The  most  typical  example  of  this  is  the 
complex  musculature  of  the  eyeball,  which  is  of  inesti- 
mable importance  in  contributing  to  all  of  the  welfare 
and  pleasure  that  result  to  one  through  vision.  The  de- 
gree of  complexity  and  the  amount  of  musculature  devoted 
to  any  one  sense  are  conditioned  by  its  needs,  which  always 


1 1 6  The  Faculty  of  Speech. 

stand  in  definite  relations  to  the  evolutionary  stage  or  pe- 
riod of  its  possessor.  In  the  human,  the  most  advanced 
product  of  evolution,  the  musculature  of  the  external  ear  is 
rudimentary,  though  not  yet  vestigial,  because  in  man  the 
sense  of  hearing  has  reached  such  a  rare  degree  of  perfec- 
tion, such  an  advanced  .stage  of  development  (it  conditions 
speech),  that  he  no  longer  requires  a  trumpet-like  apparatus 
to  turn  reflexly  in  the  direction  from  which  sounds  ema- 
nate, as  do  lower  animals.  It  is  the  same  with  the  other 
special  senses,  smell,  taste,  and  touch.  The  sniffing  move- 
ments of  smelling,  the  smacking  movements  of  tasting, 
the  delicate  movements  that  facilitate  the  tactile  sense 
and  which  reach  such  a  degree  of  acuteness  in  the  blind, 
are  all  in  evidence  to  show  how  important  a  part  move- 
ment plays  in  contributing  to  the  exquisite  function  of  a 
special  sense. 

Every  time  that  the  eyeballs  move  to  look  at  an  object, 
every  time  the  ears  are  moved  to  contribute  to  the  readi- 
ness and  completeness  with  which  the  auditory  excitation 
is  obtained  in  the  lower  animals,  there  is  stored  up  a 
memory  not  alone  of  the  object  seen  or  the  sound  heard, 
in  their  respective  situations  in  the  inferior  parietal  and 
superior  temporal  lobules,  but  a  memory  register  is  made 
of  these  movements,  kinsesthetic  memories,  and  it  is 
highly  probable  that  where  the  one  is  registered  the  other 
is  registered  also.  It  will  then  follow  that  excitation  of 
such  an  area  might  produce  movements  similar  to  those 
the  memories  of  which  are  there  enregistered.  Such 
movements  would  result  on  excitation  of  these  areas  by 
sending  the  impulses  of  excitation  to  the  Rolandic  area 
of  the  cortex ;  thus  the  movement  would  be  in  reality  an 


Conception  of  Aphasia.  117 

indirect  one  along  the  route  exactly  analogous  to  that 
travelled  by  impulses  from  the  zone  of  language  to  the 
Rolandic  cortical  area  that  result  in  articulate  speech. 

I  have  said  that  all  thought  is  externalized  by  words, 
by  acts,  or  by  previous  acts  called  deeds.  Articulate 
speech  is  the  customary  manifestation  of  thought,  but  the 
word  speech  is  often  used  generically  to  include  other 
forms  of  thought  externalization,  such  as  writing,  paint- 
ing, instrumentation,  pantomime,  etc.,  which  are  specifi- 
cally called  acts ;  and  I  use  it  in  such  generic  sense  here. 

What  is  said  for  aphasia  might  as  truthfully  be  said  for 
amusia  and  for  agraphia  if  it  were  wise  to  consider  music 
and  writing  independent  forms  of  expression,  but  it  is  not. 
Writing  and  other  forms  of  symbolic  notation  are  but 
media  to  which  mankind  attach  a  certain  conventional 
significance  in  order  to  expedite  and  harmonize  inter- 
course. The  possession  and  utilization  of  such  notation 
requires  the  integrity  of  the  zone  of  language — the  zone 
of  symbols  and  the  production  of  internal  speech.  In 
order  to  use  them,  the  memory  images,  visual,  auditory, 
and  articulatory,  must  be  revived  by  stimuli  coming  from 
without,  or  spontaneously  by  the  intelligence.  In  either 
case  they  are  jutted  into  consciousness  or  not,  as  the  case 
may  be,  after  the  completion  of  internal  language,  and 
they  are  externalized  by  motion  in  some  form.  I  have 
used  the  phrase,  "they  are  jutted  into  consciousness  or 
not,  as  the  case  may  be,"  advisedly,  for  articulated  and 
written  language  may  be  produced  without  imperfection 
during  unconsciousness.  Normal  sleep  is  the  typification 
of  unconsciousness.  The  time  occupied  by  it  is  taken 
out  of  the  cognizant  existence  of  the  individual  as  com- 


1 1 8  7^ he  Faculty  of  SpeecJi . 

pletely  as  if  he  were  dead ;  consciousness  of  the  slightest 
degree  is  antipodal  to  normal  sleep.  Yet  it  is  within  the 
experience  of  every  physician  to  have  witnessed  examples 
of  pavor  nocturnus,  somnambulism,  etc.,  in  which  articu- 
late speech,  even  to  a  considerable  extent,  was  produced. 
In  such  cases  the  speech  centres  act  harmoniously  to  an  un- 
known excitant.  The  auditory  images  of  the  word  are  in 
some  way  revivified,  and  they  in  turn  invoke  the  articu- 
latory  images  which  send  their  impulses  to  the  foot  of 
the  ascending  frontal  convolution,  from  which  they  pro- 
ceed to  cause  the  movements  of  vocalization  and  of  articu- 
lation. It  seems  very  probable  that,  when  speech  im- 
pulses from  the  zone  of  language  are  deposited  in  the 
cortical  motor  area  of  articulation,  the  latter  has  no  discre- 
tion or  decision  about  what  it  shall  do  with  them ;  it  must 
execute  them  at  once.  In  the  normal  conscious  state, 
however,  the  faculty  of  inhibition  plays  the  part  of  moni- 
tor to  this  motor  area  of  articulation  and  decides  whether 
or  not  impulses  sent  there  from  the  zone  of  language  shall 
be  externalized.  If  the  judgment  decides  that  it  is  wiser, 
more  politic,  more  humanizing,  not  to  externalize  the  mes- 
sages sent  up  from  the  speech  area,  it  will  annul  them, 
but  they  are  none  the  less  vivid  in  internal  language.  It 
is  not  necessary,  it  appears  to  me,  to  dwell  on  this,  for 
every  reader  must  be  in  possession  of  numberless  experi- 
ences conveying  the  truth  of  it.  It  is  at  trie  basis  of  so 
many  social  amenities,  the  retort  polite,  the  true  psychologi- 
cal explanation  of  turning  one  cheek  when  the  other  has 
been  smitten  instead  of  making  the  reply  that  instantly 
arises  in  the  zone  of  language,  that  I  need  dwell  no  fur- 
ther on  this  conscious  inhibition  of  execution  of  all  in- 


Conception  of  Aphasia.  1 1 9 

ternal  language.  I  wish  only  to  emphasize  that  in  states 
of  unconsciousness  the  zone  of  language  may  be  incited 
to  activity  and  send  its  finished  product  to  the  Rolandic 
area  cortex,  which  executes  it,  and  executes  it  as  it  is  sent 
there,  without  inhibition,  addition,  or  deviation  by  the 
mandates  of  consciousness.  In  similar  manner  may  be 
explained  the  aphorism  "  In  vino  veritas. "  Alcoholic  intoxi- 
cation brings  about  various  degrees  of  intellectual  abnega- 
tion, extending  up  to  profoundest  unconsciousness.  There 
is  a  degree  of  this  unconsciousness  characterized  by  a  ces- 
sation of  the  inhibitory  influences  of  consciousness  over 
the  amount  of  internal  speech  that  shall  be  externalized, 
and  when  this  stage  is  reached  the  veritas  vini  is  evident. 
The  motion  that  externalizes  ideas  may  be  of  the  fingers 
in  executing  a  musical  fantasy;  it  may  be  of  any  complex 
action  which  "  speaks  louder  than  words."  The  more  in- 
tricately co-ordinate  the  action  by  which  ideas  are  exter- 
nalized, the  more  specialized  is  its  representation  in  the 
Rolandic  area,  and  the  more  liable  is  the  localized  lesion 
to  cause  disturbance  of  it.  Articulate  speech  requires  the 
co-ordinate  action  of  a  number  of  highly  specialized  peri- 
pheral parts.  And  it  has  been  shown  beyond  parley  that 
the  larynx,  tongue,  palate,  and  lips  have  special  Rolandic 
representation,  while  those  for  the  execution  of  movements 
of  writing  have  no  other  specialization  in  the  Rolandic 
cortex  than,  that  of  the  mobile  part  which  holds  the  pen. 
Persistent  repetition  of  the  act  of  writing  may  bring  about 
such  great  facility  that  the  act  is  performed  almost  auto- 
matically;  but  practice,  though  contributory  to  perfection, 
is  not  contributory  to  the  development  of  a  special  centre; 
and  the  scrivener  does  not  possess  a  special  centre  in 


120  The  Facility  of  Speech. 

which  arc  located  the  graphic  motor  memories  any  more 
than  does  the  telegrapher  a  telegraphic  centre,  or  the 
typewriter  a  typewriting-centre,  or  the  pianist  a  special 
centre  in  which  are  represented  the  complex  movements 
of  the  fingers.  There  is  a  special  and  very  definite  corti- 
cal allocation  for  movements  of  the  hand  and  for  move- 
ments of  the  fingers,  probably  for  each  individual  finger; 
at  least  it  would  seem  to  be  definitely  proven  that  there 
is  such  representation  for  the  index  finger.  The  acquisi- 
tion of  great  dexterity  from  long  practice  in  writing  fa- 
cilitates the  readiness  with  which  such  specialized  motor 
centres  functionate,  the  same  as  practice  facilitates  the 
execution  of  all  acts,  voluntary  and  involuntary.  And 
this  facilitation  may  become  so  great  that  the  muscular 
movements  required  are  made  quite  unconsciously,  ap- 
parently automatically,  as  witness  the  movements  of  the 
telegrapher's  fingers  when  they  touch  the  keyboard,  or  of 
the  violinist  as  he  fingers  the  strings.  Nevertheless,  not- 
withstanding this  facilitation,  which  may  be  dependent 
anatomically  upon  new  association  tracts,  the  essential 
constitution  of  the  act  is  the  same  as  it  was  in  the  begin- 
ning, and  no  short  cuts  have  been  formed  nor  has  a  new 
centre  been  developed. 

I  shall  return  to  the  discussion  of  a  special  writing-cen- 
tre later  on,  but  before  doing  so  it  seems  to  me  desirable 
to  cite  some  of  the  evidence  that  may  be  offered  in  sup- 
port of  separate  localization  in  the  Rolandic  regions  for 
the  movements  of  the  larynx,  palate,  tongue,  lips,  and 
respiratory  movements  before  taking  up  a  discussion  of 
the  constitution  of  the  speech  area  and  the  closer  relation 
of  the  centres  there  situate  to  other  parts  of  the  brain. 


Conception  of  ApJiasia.  1 2 1 

Because  of  the  importance  that  I  attribute  to  clinico-path- 
ological  observation  in  comparison  with  the  experiment- 
al, although  fully  cognizant  of  the  great  value  of  the 
latter,  I  shall  cite  first,  as  briefly  as  possible,  a  few  cases 
that  have  been  studied  clinically  and  anatomically  which 
seem  to  give  unequivocal  support  to  such  localization. 
And  before  doing  this,  I  shall  call  the  reader's  attention 
to  the  necessity  of  bearing  in  mind  that  in  this  mono- 
graph the  term  Broca's  convolution  is  not  used  in  the 
sense  which  many  writers  of  the  last  generation  would 
give  to  it— to  include  the  foot  of  the  third  frontal  convo- 
lution, the  lower  part  of  the  ascending  frontal  convolution, 
and  the  lower  part  of  the  ascending  parietal  convolution, 
and  thus  not  only  the  entire  frontal  operculum  but  a  part 
of  the  parietal  as  well.  In  this  treatise  the  term  Broca's 
convolution  is  used  synonymously  with  "  foot  of  the  third 
frontal  convolution,"  and  its  physiological  synonym  may 
be  said  to  be  "  centre  for  articulatory  kinaesthetic  images." 
A  case  reported  by  Elder1  is  one  of  much  importance. 
The  essentials  of  this  case  are  as  follows :  A  man  sixty 
years  old,  who  had  previously  been  healthy,  suddenly 
developed  difficulty  in  speaking.  Speech  became  in- 
distinct and  blurred,  and  saliva  trickled  from  the  mouth. 
On  the  following  day  he  was  so  weak  that  he  demanded 
admission  to  the  hospital,  and  it  was  then  found  that 
there  was  paresis  of  the  right  side  of  the  face,  more 
marked  in  the  lower  part  and  at  the  angle  of  the  mouth 
and  not  involving  the  orbicularis  palpebrarum.  The  pa- 
tient was  perfectly  conscious,  understood  everything  that 
was  said  to  him,  had  no  hemiplegia,  and  his  only  trouble 

1  Elder  :   Edinburgh  Hospital  Reports,  vol.  :ii.,   1895. 


122  TJie  Faculty  of  Speech. 

apparently  was  incapacity  to  enunciate  words,  due  to  diffi- 
culty in  moving  the  tongue,  lips,  and  other  muscles  of  artic- 
ulation as  readily  as  was  necessary.  There  was  no  aphasia. 
The  voice  was  unimpaired.  He  could  protrude  the  tongue, 
although  it  came  out  rather  slowly,  and  there  was  diffi- 
culty in  swallowing  liquids.  The  patient  grew  weak  very 
rapidly  and  died  five  days  after  the  occurrence  of  the  dys- 
arthria,  the  immediate  cause  of  death  being  hypostatic 
pneumonia,  coma,  but  no  hemiplegia  having  preceded 
death.  On  examination  of  the  brain,  there  was  found  in 
the  lower  part  of  the  ascending  frontal  convolution,  about 
half  an  inch  from  the  Sylvian  fissure,  a  blood  clot  which 
had  pushed  its  way  through  the  cortex  and  which  could 
be  seen  before  cutting  into  the  hemisphere,  so  completely 
had  it  destroyed  the  cortical  substance.  On  slitting  the 
brain  horizontally,  the  blood  clot  was  found  to  contain 
about  two  drachms  of  blood,  situated  at  the  level  of  the 
lower  part  of  the  ascending  frontal  and  the  ascending 
parietal  convolutions.  It  had  destroyed  almost  entirely 
the  cortical  substance  of  the  lower  end  of  these  convolu- 
tions. It  did  not  involve  quite  the  whole  of  the  lower 
end  of  the  ascending  frontal,  as  there  remained  intact  a 
strip  of  cortex  adjoining  the  foot  of  the  third  frontal. 
The  foot  of  the  third  frontal  was  quite  intact.  The  ac- 
companying diagram  shows  the  extent  of  the  lesion,  both 
as  it  appeared  from  a  view  of  the  uncut  hemisphere  and 
on  horizontal  section  (Fig.  n,  A).  Internally,  the  hem- 
orrhage extended  inward  and  forward  immediately  about 
the  level  of  the  lenticular  nucleus  in  a  very  thin  layer  for 
about  two-thirds  of  the  distance  between  the  cortical  sur- 
face and  the  internal  surface  of  the  hemisphere.  Its  far- 


Conception  of  Aphasia, 


123 


thest  point  internally  was  close  to  the  anterior  limb  of  the 
internal  capsule  and  quite  in  front  of  the  motor  tract. 
The  situation  and  extent  of  the  lesion  is  shown  in  pip;, 
n,  B. 

This  observation  is  almost  equal  to  a  mathematical 
demonstration,  so  convincing  is  it  that  a  localized  lesion 
of  parts  of  the  cortex  which 
are  strictly  motor,  namely, 
the  Rolandic-area  cortex, 

./i 

may  when  diseased  be  at- 
tended by  inability  to  make 
the  peripheral  associations 
or  movements  necessary  for 
speech.  It  is  not  the  only 
one  of  its  kind  on  record, 
but  it  is  the  most  con- 
vincing one  on  account  of 
the  fact  that  there  were  no 
complicating  lesion  and,  of 
course,  no  other  symptoms. 
Then  the  strictness  with 
which  the  lesion  was  con- 
fined to  the  lower  part  of 
the  Rolandic  cortex,  i  t  s 
sharp  delimitation  from  the 
third  frontal  convolution, 
and  the  rapidity  with  which 
death  followed  the  occur- 
rence of  the  lesion,  all  tend  to  make  it  an  ideal  case  in 
proof  of  the  claim  of  separate  localization  for  the  peri- 
pheral speech  mechanism. 


Fig.  ii.— Ay  Subdivision  of  Broca's 
convolution,  according  to  Elder,  a, 
Centre  of  psycho-motor  speech  im- 
ages ;  b,  centre  for  adduction  of  vo- 
cal cords ;  c  and  </,  articulo-motor 
centre  ;  e  /  g;  centre  for  lower  and 
upper  face,  respiratory  movements  of 
larynx,  respectively  ;  dotted  circle  in- 
dicates seat  of  lesion.  .#,  Lesion  on 
cross-section. 


124  The  Faculty  of  Speech. 

Cases  in  which  there  has  been  subcortical  lesion  of  the 
motor  tracts  that  come  from  somewhat  indefinite  parts  of 
the  Rolandic  area  are  recorded  to  a  considerable  number; 
but,  no  matter  how  carefully  they  have  been  observed  or 
the  pathological  lesion  has  been  described  or  depicted, 
they  never  can  be  offered  as  absolute  proof,  because 
the  fibres  which  are  interrupted  by  such  a  subcortical  focus 
of  disease  can  never  be  said  positively  to  come  from  a 
definite  localized  part  of  the  cortex.  Moreover,  it  is  ex- 
tremely rare  for  a  subcortical  lesion  to  be  so  limited  that 
it  will  sever  the  fibres  going  from  one  small  area  of  the 
cortex  and  leave  intact  all  the  others,  for  it  will  be  remem- 
bjrcd  that  the  projection  fibres  continually  approximate 
one  another  from  the  time  they  leave  the  cortical  cells 
until  they  are  brought  into  the  internal  capsule,  where  they 
are  crowded  together  in  a  space  that  is  little  more  than 
visible  to  the  naked  eye. 

Dejerine1  has  described  two  cases  of  subcortical  lesion 
in  which  a  small  area  of  softening  existed  just  internal  to 
the  anterior  nart  of  the  foot  of  the  ascending  frontal  con- 
volution. These  patients  had  the  symptom  complex  of  sub- 
cortical  motor  aphasia  and  were  not  hemiplegic,  which 
shows  that  the  lesion  was  not  of  sufficient  extent  to  involve 
any  of  the  projection  fibres  coming  from  the  arm  or  the  leg 
areas.  The  only  discordant  symptom  in  these  cases  of 
Dejerine  was  that  in  both  cases  there  existed  a  degree  of 
paralysis  of  the  right  vocal  cord;  in  one  case  the  paralysis 
was  complete,  and  in  the  other  partial.  This  is  in  contra- 
diction to  the  findings  of  experimentalists,  who  believe  that 

1  Dejerine  :  "  Aphasie  motrice  sous-corticale  et  localisation  cerebrale  des 
centres  larynges."  Societe  Biologic,  1891,  p.  97. 


Conception  of  Aphasia.  125 

the  vocal  cords  have  a  bilateral  and  double  representation; 
that  is,  stimulation  of  the  vocal-cord  centre  on  one  side 
of  the  brain  will  cause  adduction  of  both  vocal  cords,  and 
therefore  lesion  of  one  side  should  not  cause  complete 
paralysis  of  either  vocal  cord.  This  apparent  contradic- 
tion, however,  should  not  stand  in  the  way  of  utilizing 
the  cases  to  prove  that  a  lesion  subcortically  situated  in 
the  brain,  that  cuts  off  the  projection  fibres  coming  from 
the  lower  end  of  the  ascending  frontal  convolution,  will  be 
followed  by  a  degree  of  dysarthria  which  may  be  so  com- 
plete that  the  patient  is  devoid  of  articulate  speech,  and 
therefore  of  proving  that  the  movements  necessary  for  ar- 
ticulate speech  have  a  cortical  representation  all  in  one 
definite  area  of  the  Rolandic  zone. 

Bernheim1  has  recorded  a  case  which  indicates  with  a 
good  deal  of  directness  the  cortical  localization  of  lingual 
movements.  Clinically,  there  was  pronounced  deviation 
of  the  tongue  to  the  right ;  no  other  paralysis,  and  no 
aphasia.  After  death  there  was  found  a  sarcomatous  blood 
cyst,  five  to  six  millimetres  long,  located  near  the  inferior 
border  of  the  left  ascending  frontal  convolution,  about  six 
millimetres  behind  the  sulcus  which  separates  it  from  the 
third  frontal. 

An  observation  of  Garel  *  is  strikingly  corroborative  of 
Dejerine's  contention  that  the  cortical  laryngeal  centre  is 
situated  in  the  lower  end  of  the  ascending  frontal  convolu- 
tion. In  this  case,  the  principal  symptom  was  paralysis 
of  the  vocal  cords.  The  autopsy  showed  a  localized  me- 

1  Bernheim  :  "Contribution  a  1'etude  des  aphasies."  Rev.  Med.,  pp. 
372-388,  1891. — "Des  aphasies."  Congres  Francais  de  Med.  Interne, 
Lyon,  1894. 

*darel  :  Ann.  des  Mai.  de  1'Oreille,  du  Larynx,  etc.,  April,  1890. 


126  The  Facility  of  Speech. 

ningo-encephalitis  at  the  lower  end  of  the  right  ascending 
frontal  convolution. 

The  cortical  representation  of  the  laryngeal  muscles  .has 
been  carefully  studied  by  Krause,  by  Masini,  Beevor,  and 
by  Horsley  and  Semon.  Their  conclusions  regarding  the 
centre  for  the  laryngeal  movements  are  very  much  in  ac- 
cord. They  show  that  in  the  ape  the  centre  for  the  larynx 
is  situated  in  the  anterior  part  of  the  foot  of  the  ascending 
frontal  convolution,  that  the  representation  is  bilateral,  but 
that  the  preponderant  representation  for  the  vocal  cords  of 
one  side  is  in  the  opposite  hemisphere,  and  that  each  hem- 
isphere governs  the  movements  of  both  vocal  cords.  Wal- 
lenberg has  published  a  case  in  which  there  was  laryngeal 
paralysis  of  the  left  side,  and  the  projection  fibres  from  the 
portion  of  the  cortex  in  which  the  laryngeal  centre  is  situ- 
ated were  entirely  destroyed.  The  experimental  physiolo- 
gists furthermore  have  proven  that  in  the  anthropoid  the 
centres  for  the  movements  of  the  lip  and  the  tongue  are 
situated  in  the  lower  part  of  the  ascending  frontal  and 
the  ascending  parietal  convolutions,  and  that  these  move- 
ments are  not  represented  in  any  way  in  the  third  frontal 
convolution.  They  have  shown,  furthermore,  that  the 
centres  for  the  movements  of  the-  muscles  of  the  tongue, 
throat,  and  mouth  are  situated  adjacent  to  one  another  in 
the  central  convolutions  on  either  side  of  the  fissure  of 
Rolando,  and  that  the  centres  for  the  angle  of  the  mouth 
and  the  upper  part  of  the  face  are  placed  higher  up,  tow- 
ard what  is  generally  known  as  the  face  area. 

The  part  of  the  cortex  to  which  the  centre  for  respiratory 
movements  is  allocated  is  yet  unknown.  Respiration  is 
essential  to  speech,  and,  although  we  may  produce  sep- 


Conception  of  Aphasia.  127 

arately  the  three  distinct  mechanisms  of  respiration,  vocal- 
ization, and  articulation,  it  is  by  the  simultaneous  activity 
and  co-ordination  of  these  three  that  perfect  speech  is  pro- 
duced. As  respiration,  then,  seems  to  be  one  of  this  im- 
portant triad,  and,  as  it  is  positively  proven  that  the  other 
two  have  a  cortical  representation  in  the  Rolandic  region, 
it  seems  reasonable  to  assume  that  there  is  a  cortical  centre 
or  area  for  respiration.  This  representation  is  a  diffi- 
cult one  to  prove,  because  respiration  is  more  completely 
under  the  control  of  the  reflex  centre  situated  in  the 
oblongata  than  is  any  other  function.  The  only  experi- 
mental evidence  that  can  be  utilized  in  favor  of  the 
localization  of  the  movements  of  respiration  is  that 
of  Horsley  and  Semon,  who  found  that  stimulation  of 
the  frontal  convolution  immediately  adjacent  to  the  face 
area  in  the  ascending  frontal  caused  an  increase  in  the 
rate  and  in  the  force  of  respiratory  movements.  In  the 
dog  and  in  the  cat,  Franck  has  shown  that  by  stimu- 
lation of  the  motor  areas  of  the  cortex  decided  accelera- 
tion or  slowing,  according  to  the  duration  and  the  intensity 
of  the  stimulation,  v/as  prodrced. 

After  this  brief  account  of  the  separate  localization 
of  parts  concerned  in  the  externalization  of  articulate 
speech,  I  may,  before  discussing  the  relation  of  speech  to 
consciousness,  intelligence,  or,  in  general,  to  the  frontal 
lobes,  revert  for  a  moment  to  the  relative  positions  of  the 
centres  of  speech  in  the  area  of  language.  As  I  have  pre- 
viously said,  these  centres  are  three  in  number :  the  centre 
for  auditory  memories,  the  centre  for  visual  memories,  and 
the  centre  for  articulatory  kinaesthetic  memories.  The  lat- 
ter, unfortunately,  is  often  called  the  centre  for  motor  memo- 


128  The  Faculty  of  Speech. 

ries.  These  three  centres  have  a  very  definite  localization, 
and  their  position  is  of  great  ontogenetic  importance.  The 
centre  in  which  are  stored  the  images  of  articulation  is 
situated  in  the  third  frontal  convolution  immediately  adja- 
cent to  that  portion  of  the  Rolandic  cortex  the  cells  of  which 
give  origin  to  the  projection  fibres  going  to  the  tongue, 
the  lips,  and  the  larynx ;  that  is,  to  the  parts  which  supply 
the  peripheral  mechanism  of  articulate  speech.  Where 
else  should  such  a  centre  be,  if  its  fullest  integrity  were 
desired,  than  immediately  adjacent  to  the  part  whose  com- 
missions it  executes?  The  centre  in  which  are  stored  the 
visual  images  is  situated  in  a  definite  part  of  the  inferior 
parietal  lobule,  in  that  portion  of  the  lobule  known  as  the 
angular  gyrus,  and  if  we  have  in  mind  the  central  projec- 
tions of  the  optic  tract  after  it  leaves  the  external  genicu- 
late  body,  the  anterior  quadrigeminal  body,  and  the  pulvinar 
of  the  thalamus,  until  they  reach  the  lingual  and  fusiform 
lobules  bordering  the  calcarine  fissure,  we  shall  appreciate 
that  the  angular  gyrus  is  the  most  direct,  the  most  adja- 
cent, and  the  most  elective  place  in  which  the  visual  images 
could  be  stored.  In  fact,  its  relationship  to  the  primary 
visual  centre  and  to  the  fibres  that  convey  visual  im- 
pulses, the  radiations  of  Gratiolet,  is  analogous  to  the  en- 
vironmental relationship  between  the  centre  for  art i dilatory 
memories  and  the  Rolandic  cortex  that  externalizes  speech, 
but  there  must  always  be  a  revivification  of  the  articu- 
latory  kinaesthetic  memories  before  speech  can  be  pro- 
duced. The  third  centre,  the  auditory  centre,  the  most 
important  of  all  speech  centres,  the  one  by  whose  func- 
tioning speech  is  developed,  the  one  that  conditions  speech 
more  than  do  both  the  others  combined,  the  one  in  which 


Conception  of  Aphasia.  \  29 

words  are  primarily  revived  in  the  vast  majority  of  peoples, 
the  one  that  is  least  tolerant  of  disorder  without  mani- 
festing itself  by  imperfections  of  speech,  is  situated  be- 
tween these  two  centres  in  the  zone  of  language,  and  oc- 
cupies the  first  temporal  convolution  and  particularly  that 
portion  of  the  cortex  which  surrounds  the  temporo-parietal 
sulcus.  It  occupies  such  a  position  in  relation  to  the  dis- 
tribution of  the  auditory  nerves  and  the  mechanism  of 
hearing  that  experimentalists  as  well  as  clinicians  have 
been  led  to  posit  it  as  a  general  auditory  area.  The 
centre  for  the  storage  of  auditory  memories  is  not  placed 
anywhere  in  the  general  auditory  area :  it  is  placed  in 
the  posterior  part  of  the  first  temporal  immediately  ad- 
jacent to  the  gyrus  in  which  are  stored  visual  memories. 
Thus  it  will  be  seen  that  the  auditory  and  visual  mem- 
ories which  are  contributory  to  the  development  of  speech 
and  education  in  general  are  not  widely  separated.  They 
are  not  so  far  removed  from  each  other  that  a  great  dis- 
tance must  be  travelled  before  the  products  of  one  can  be 
compared  with  those  of  another ;  they  are,  on  the  contrary, 
immediately  adjacent.  On  the  other  hand,  they  are  not 
adjacent  to  the  centre  in  which  are  stored  the  memories  of 
articulation,  and  to  which  the  products  of  the  activity  of 
the  former  two  are  sent  before  they  go  to  the  Rolandic- 
area  cortex  to  be  executed.  Furthermore,  the  location  of 
the  visual  and  auditory  centres  on  the  one  hand,  and  of  the 
centre  for  articulatory  memories  on  the  other,  would  seem 
to  me  to  have  a  very  definite  suggestiveness  in  relation  to 
the  frontal  lobes,  which  physiologists,  psychologists,  and 
pathologists  believe  to  be  the  most  essential  parts  of  the 
brain  for  the  production  of  the  higher  mental  processes — 
9 


130  The  Faculty  of  Speecli. 

judgment,  will,  inhibition,  and  emotions  —  and  whose 
integrity  must  be  maintained  if  the  individual  is  to  de- 
velop or  persist  in  habits  of  attention,  concentration  of 
thought,  balance  of  feeling,  sound  judgment,  and  moral 
conduct.  In  a  previous  portion  of  this  chapter  we  have 
referred  to  the  important  part  played  by  consciousness 
or  intelligence  in  the  faculty  of  speech.  The  relation 
which  the  zone  of  language  bears  to  the  frontal  con- 
volution, topographically  and  morphologically,  is  not 
without  its  significance.  A  glance  at  Fig.  7  which  repre- 
sents the  zone  of  language  will  show  that  it  is  on  the 
lateral  surface  of  the  brain;  that  behind,  it  is  contigu- 
ous with  the  visual  area ;  below,  with  the  auditory  area ; 
above,  with  the  motor  executive  area,  and  in  front  with 
the  intellectual  area.  This  speech  zone,  this  zone  of  lan- 
guage, receives  information ;  it  is  apperceptive  of  impulses 
coming  into  it,  mainly  from  below  and  behind;  it  sub- 
mits them  to  the  area  in  front,  and  they  are  externalized 
by  the  Rolandic  area.  It  is,  then,  one  great  association 
sphere  of  the  brain,  in  which  are  located  for  reasons  of 
expediency  certain  centres  for  the  reception  of  impulses. 
But  the  reception  of  impulses  alone  could  not  give  rise  to 
intelligent  speech.  Even  granting  them  a  certain  auton- 
omy, they  could  give  rise  only  to  an  echo  of  the  impulse, 
and  this  is  often  beautifully  illustrated  in  certain  forms 
of  sensory  aphasia  in  which  one  of  the  centres  is  destroyed 
and  the  circuit  for  internal  speech  broken ;  the  patient, 
though  still  capable  of  receiving  in  his  zone  of  language 
some  speech  impulses,  has  not  the  means  to  co-ordinate 
them  and  submit  them  to  the  intelligence,  and  he  can  only 
echo  sounds  heard,  a  condition  called  echolalia. 


Conception  of  Aphasia.  1 3 1 

Pathological  observation  and  clinical  experience  are  in 
fullest  accord  with  this  conception  of  language,  and  if 
clinical  experience  has  proven  one  fact  more  conclusively 
than  another  to  the  satisfaction  of  trustworthy  observers, 
it  is  that  no  centre  of  this  zone  of  language  can  become 
disorganized  without  there  appearing  a  perversion  of  func- 
tion, not  alone  of  the  centre  that  is  destroyed,  but  of 
all  the  others ;  in  short,  that  in  every  form  of  genuine 
aphasia,  whether  it  be  so-called  motor,  auditory,  or  visual, 
there  is  some  perversion  of  idea  externalization  and  of 
language.  It  is  to  Dejerine  and  his  pupils,  Mirallie, 
Thomas  and  Roux,  that  we  owe  the  proof  of  this  state- 
ment more  than  to  any  others,  and  to  them  we  cheerfully 
accord  deserved  praise  for  maintaining  their  contention  in 
the  face  of  very  nearly  universal  opposition. 

Perversion  of  internal  language  is  manifest  most  dis- 
cernibly  by  disorder  of  internal  reading.  During  the 
past  few  years  I  have  examined  all  my  cases  of  aphasia, 
whether  motor  or  sensory,  with  the  object  in  view  of  de- 
termining whether  or  not  there  was  defect  of  internal  or 
mental  reading,  and  thus  of  corroborating  the  statement 
of  Dejerine.  I  have  found  that  in  every  case,  without 
exception,  examined  with  sufficient  care  and  patience  and 
in  the  right  way,  there  was  detectable  loss  of  the  ability 
to  read  mentally.  Naturally,  it  is  in  the  cases  of  cor- 
tical motor  aphasia  that  the  results  are  of  great  im- 
portance, for  in  genuine  sensory  aphasia,  visual  and 
auditory,  there  necessarily  exists  disturbance  of  mental 
reading.  As  I  shall  say  in  the  chapter  on  articulatory 
or  true  motor  aphasia,  disturbance  of  reading  has  been 
noted  by  nearly  every  observer  from  the  time  of  Trous- 


132  The  Faculty  of  Speech. 

seau,  and  various  explanations  have  been  put  upon  its 
occurrence,  the  usual  one  being  that  it  was  the  result  of 
either  a  slight  dementia  or  a  mixed  aphasia.  According 
to  the  conception  of  aphasia  which  I  have  attempted  to 
outline,  defect  of  mental  reading  is  just  as  likely  to  oc- 
cur in  a  patient  with  cortical  motor  aphasia,  although  not 
so  profoundly,  as  in  a  patient  with  auditory  aphasia. 

The  degree  of  dyslexia  that  occurs  when  the  convolu- 
tion of  Broca  is  diseased  is  discussed  in  another  chapter 
(Chapter  V.),  but  it  needs  to  be  mentioned  here  that  one 
reason  for  its  less  common  recognition,  and  therefore  for 
the  unwillingness  on  the  part  of  certain  writers  to  admit 
its  occurrence,  is  the  fact  that  after  it  has  existed  for  a 
certain  length  of  time  it  is  only  slight  and  very  often 
latent.  These  patients  essay  to  read  and  often  busy  them- 
selves for  hours  with  books  and  papers,  from  which  they 
apparently  get  the  customary  enjoyment  and  diversion. 
On  the  other  hand,  after  the  alexia  has  lasted  for  a  time, 
the  patient  may  learn  anew  to  read,  and  the  fact  that  he 
learns  anew  in  a  manner  which  is  entirely  the  reverse  of 
that  which  he  employed  when  a  child  has  been  used  by 
modern  pedagogues  as  an  argument  in  favor  of  the  word- 
and-syllable  method  of  learning  to  read.  The  patient  with 
cortical  motor  aphasia  who  must  re- learn  to  read  does  so 
by  first  getting  the  perspective  of  the  word,  the  outline, 
then  the  syllables  that  constitute  the  word,  and,  last  of  all, 
the  letters  and  their  association  that  enter  into  the  forma- 
tion of  the  word.  Thus  they  learn  to  read  in  a  way  simi- 
lar to  that  at  present  advanced  by  many  educationalists, 
and  the  reverse  of  the  way  in  which  most  of  us  learned  to 
read. 


Conception  of  Aphasia.  133 

It  will  be  seen  at  a  glance  how  materially  this  concep- 
tion of  aphasia  differs  from  that  which  is  taught  by  a  ma- 
jority of  writers  on  the  subject  of  aphasia  to-day.  Even 
the  most  recent  writers  on  the  subject,  those  who  essay 
to  contribute  to  our  knowledge  of  aphasia,  of  whom  we 
may  mention  Wyllie,  Elder,  and  others,  as  well  as  those 
who  have  no  such  object,  who  merely  restate  in  their  own 
way  that  which  passes  as  current  knowledge,  describe  dif- 
ferent forms  of  aphasia  and  the  different  centres  diseased 
to  produce  these  forms,  as  if  the  faculty  of  language  were 
made  up  of  a  different  set  of  entities  and  each  of  these 
entities  were  localized  to  a  different  part  of  the  brain. 
The  conception  of  aphasia  that  passes  muster  to-day  with 
the  majority  of  writers  is  one  suggested  by  Marce,  in 
1856,  and  which  was  adopted  by  Charcot ;  and  the  wide 
dissemination  and  acceptance  that  have  been  given  to  it 
are  largely  due  to  the  assiduous  and  lucid  teachings  of  the 
latter.  I  shall  now  concern  myself  particularly  in  showing 
that  these  views  are  no  longer  tenable.  At  the  very  outset, 
I  wish  to  say  that  it  is  not  the  logic  of  the  arguments  of 
Charcot  and  his  followers  with  which  I  am  concerned, 
but  it  is  with  the  original  contention,  which  is,  I  believe, 
entirely  unwarranted. 

Charcot  and  his  school,  as  well  as  many  other  writers  on 
aphasia  who  are  entirely  opposed  to  Charcot' s  concep- 
tion of  it,  such  as  Bastian,  believe  that  there  are  four 
speech  centres.  I  have  already  stated  that  the  Charcot 
school  teaches  the  autonomous  action  of  these  centres, 
although  admitting  that  they  have  a  certain  functional 
interrelationship.  These  centres  on  the  emissive  side  of 
language  are  the  articulatory  motor  and  the  graphic  motor, 


134  The  Faculty  of  Speech. 

and  on  the  receptive  side  the  centres  for  auditory  images 
and  for  visual  images.  These  centres  have  a  definite  au- 
togenetic  individuality,  which  is  augmented  decidedly  by 
education.  Depending  upon  this  congenital  or  inherited 
tendency  for  the  predominance  of  one  centre  over  an- 
other, and  contributed  to  by  education,  the  individual 
acquires  a  knowledge  of  things,  their  properties,  their 
names,  their  usage,  principally  by  the  employment  of  one 
of  these  centres.  In  speech,  words  are  revived  predomi- 
nantly by  the  activity  of  one  of  these  centres,  and  in 
speaking  he  orients  himself  through  the  activity  of  this 
individual  centre.  Depending  upon  the  centre  that  plays 
such  an  important  part  in  the  primary  revival  of  words,  the 
individual  is  said  to  be  a  visuel,  a  moteur,  an  audit  if,  a 
gmpJiic  moteur,  or  an  indifferent,  both  in  the  acquisition 
of  knowledge  by  language  and  in  the  use  of  knowledge  by 
language.  Leaving  aside  for  the  time  being  the  fact  that 
psychology,  physiology,  and  pathology  are  in  accord  in 
denying  the  autonomous  existence  of  any  one  of  these 
centres,  this  theory  of  Charcot  and  of  his  followers  must 
stand  or  fall  with  the  existence  of  the  four  centres,  and  I 
venture  to  believe  that  we  are  in  possession  of  sufficient 
evidence  to  deny  the  existence  of  a  graphic  motor  centre. 
I  have  striven  to  show  that  the  zone  of  language  con- 
tains three  centres,  each  of  them  the  seat  of  memory 
images  of  a  sensory  nature  and  none  of  them  of  absolute 
autonomous  activity.  That  they  are  relatively  inter- 
dependent, and  that  one  cannot  be  deranged  without 
causing  some  disturbance  in  the  totality  of  function 
of  these  three  centres,  has  already  been  shown.  Indeed, 
in  the  early  history  of  aphasia,  before  Broca  made  his 


Conception  of  Aphasia.  135 

memorable  observations,  Naugere  taught  that  disturbance 
in  the  production  of  one  component  of  speech  manifested 
itself  by  disorder  of  all  the  others.  These  teachings 
were  followed  by  Gairdner  and  by  the  Nestor  of  English 
neurologists,  Hughlings  Jackson.  According  to  the  the- 
ory of  Charcot,  the  emissive  centres  of  speech,  the  articu- 
latory  motor  centre  and  the  graphic  motor  centres,  are 
loci  in  which  are  stored  the  motor  memories  of  articulation 
and  the  motor  memories  that  guide  the  hand  in  writing. 
Indeed,  it  is  not  entirely  apparent  that  this  savant  was 
not  of  the  opinion  that  these  centres  are  the  places  in 
which  originate  the  motorial  impulses  that  are  external- 
ized as  speech  and  as  writing.  The  localization  of  these 
two  autonomous  centres  Charcot  believed  to  be  absolute, 
and  he  fixed  the  one  for  graphic  motor  images  in  the  foot 
of  the  second  frontal  convolution,  and  that  for  articulatory 
motor  images  in  the  foot  of  the  third  frontal.  The  fre- 
quent association  of  motor  agraphia  and  motor  aphasia  he 
explained  by  the  juxtaposition  of  the  centres,  and  he 
averred,  apparently  in  the  face  of  conclusive  contradictory 
evidence,  that  a  lesion  that  destroys  the  third  frontal  does 
not  entail  agraphia.  The  coexistence  of  motor  agraphia 
with  motor  aphasia  he  claimed  was  not  necessary,  and  it 
might  be  said  that  since  then  his  pupils,  Pitres,  Grasset, 
Marie,  Brissaud,  and  others  have  claimed  the  same  and 
contend  that  there  are  cases  of  pure  motor  agraphia  with- 
out aphasia,  but  the  cases  they  cite  to  substantiate  their 
position  do  not  stand  the  test  of  analytic  scrutiny 

It  will  readily  be  seen  how  opposed  to  our  conception 
of  speech  and  of  the  function  of  the  zone  of  language 
is  this  conception  of  Charcot.  In  one  word,  according 


136  The  Faculty  of  Speech. 

to  his  teaching,  the  centre  is  all- important ;  according  to 
ours,  the  centres  are  important,  but  only  as  one  indi- 
vidual in  a  community.  I  have  no  intention  of  dwelling 
further  on  this  distinction,  except  to  show  the  untenability 
of  the  position  of  the  school  of  Charcot  by  discussing  the 
existence  of  a  graphic  motor  centre. 

Is    there  a   GrapJdc    Motor  Centre  for   Registration  and 
Regulation  of  Writing- Movements  f 

The  most  important  evidence  that  the  claimants  for  the 
existence  of  a  graphic  motor  centre,  in  which  are  stored 
the  motor  images  of  writing  (which  by  this  school  are 
looked  upon  as  a  constituent  part  of  the  idea  of  the  word), 
can  offer  is  that  which  was  furnished  by  Exner,1  of  Vi- 
enna, in  1 88 1.  It  is  not  hazarding  the  truth  to  say  that 
the  evidence  offered  by  Exner  in  support  of  the  exist- 
ence of  such  a  centre  would  not  be  admitted  as  proof  in 
any  other  department  of  science  than  medicine.  Never- 
theless, it  has  been  admitted  to  the  latter  and  it  must, 
therefore,  be  discussed.  It  was  the  necessity  for  the 
existence  of  such  a  centre  apparently  that  led  Exner  to 
seek  it,  and  Charcot,"  seeing  in  it  a  contribution  to  his 

1  Exner:  "  Untersuchungen  liber  die  Localisation  der  Functionen  in 
der  Grosshirnrinde  des  Menschen." 

*  It  is  astonishing  how  universally  accepted  is  the  existence  of  a  particu- 
lar or  undivided  graphic  motor  centre.  Writer  after  writer  accepts  the 
findings  of  Exner  in  a  way  that  leaves  the  impression  that  no  doubt  can 
possibly  exist  concerning  the  reality  of  the  centre.  Even  Bastian,  who  is 
not  a  believer  in  the  complete  topographical  distinctness  of  the  several 
sensory  centres  in  the  cerebral  hemispheres,  and  who  has  been  one  of  the 
most  unswerving  opponents  to  the  conception  of  aphasia  taught  by  the 
school  of  Charcot,  says,  in  the  Lumleian  Lectures,  the  first  of  which  ap- 
peared after  this  monograph  was  practically  finished,  that  "  the  grapho-motor 
centre  can  be  localized  with  nearly  as  much  confidence  as  the  articulatory 


Conception  of  Apkasia.  137 

theoretical  exposition  of  the  faculty  of  language,  ac- 
cepted it. 

Exner  made  an  artificial  division  of  the  external,  internal, 
and  inferior  surfaces  of  the  cerebral  cortex.  There  was  no 
method  in  his  division,  no  rule,  no  preconception.  So  far 
as  possible  the  principal  fissures  were  the  lines  of  separation 
of  these  artificially  outlined  areas,  but  this  was  merely  for 
the  sake  of  convenience  and  ease  of  orientation.  The  areas 
had  different  shapes  and  sizes,  so  that  when  the  division 
was  made  the  result  might  be  compared  to  a  territorial 
map  of  the  United  States.  If  one  will  look  at  such  a 
map,  he  will  see  that  oftentimes  natural  divisions,  rivers 
and  mountains,  separate  the  States.  These  are  the  prin- 
cipal fissures  of  Exner,  but  in  most  cases  the  division  is 
arbitrary.  He  then  searched  the  literature  of  local  brain 
disease  and  made  notes  of  three  hundred  and  sixty-seven 
cases,  to  find  how  many  times  any  one  area  was  the  seat 
of  lesion  in  the  cases  observed  and  how  often  each  area 
was  affected  when  individual  symptoms  had  been  observed 
in  relation  to  the  disease. 

I  do  not  deem  it  necessary  to  give  the  details  of  his 
analysis  but  may  say  that  the  majority  of  his  conclu- 
sions do  not  correspond  with  the  present  teachings  as  to 
cerebral  localization.  The  correspondences  that  do  exist 
might  laudably  be  explained  by  chance.  The  fact  that 

kinaesthetic  centre."  There  is  such  a  dubiousness  about  his  further  state- 
ment of  its  localization  that  I  shall  quote  his  exact  words.  "  The  tendency 
for  some  years  has  been  to  follow  Exner,  who  believes  the  graphic  motor 
centre  to  be  situated  in  the  posterior  part  of  the  second  frontal  gyrus, 
though  we  shall  see  later  the  evidence  in  favor  of  this  localization  is  at 
present  extremely  scanty.  All  that  can  be  said  on  this  point,  therefore,  is 
that  we  know  approximately  where  to  look  for  it."  This,  it  would  seem  to 
me,  scarcely  warrants  the  language  of  the  first  quotation. 


138  The  Faculty  of  Speech. 

every  brain  varies  in  fissuration,  in  convolutional  area,  and 
in  formation,  and  the  fact  that  no  one  surface  marking  can 
be  taken  to  fit  another  brain,  make  it  difficult  to  see  how 
any  definite  inferences  could  be  drawn  from  such  a  method 
of  investigation.  This  method  would  seem  to  me  to  be 
paralleled  if  a  sociologist  who  had  become  convinced  of  a 
definite  locus  for  homicides  should  set  to  work  to  substan- 
tiate his  contention  by  getting  statistics  of  the  number  of 
men  slain  in  the  United  States,  let  us  say  in  ten  years, 
and  then  statistics  to  show  how  many  homicides  were  to  be 
found  living  in  any  State,  and  how  many  times  the  victims 
were  found  in  any  given  State.  The  State  that  had  the 
greatest  number  of  homicides  and  the  greatest  number  of 
victims  would  be  a  homicidal  centre.  It  would  depend 
upon  the  sociologist  whether  or  not  that  State  would  be 
considered  the  only  homicidal  centre.  In  seventy-three 
of  Exner's  cases  there  were  lesions  that  gave  rise  to  paral- 
ysis of  the  face,  and  of  these  about  one-half  were  grouped 
in  the  median  part  of  the  ascending  central  convolution, 
while  four  of  them  showed  lesion  of  the  third  frontal ; 
fourteen,  lesion  of  the  second  frontal ;  eleven,  lesion  of 
the  angular  gyrus ;  eight,  lesion  of  the  first  temporal,  etc. 
It  must  be  granted  that  such  contributions  as  these  are 
not  of  much  service  in  helping  to  give  brain  localization 
scientific  exactitude.  Let  us  take,  for  instance,  another 
example.  The  lesion  in  one  hundred  and  thirty-one  cases 
was  one  that  caused  paralysis  of  the  upper  extremity,  and 
in  eight  of  these  cases  the  third  frontal  was  the  seat  of 
lesion,  in  thirteen  the  second  frontal,  in  eleven  the  first 
frontal,  in  twenty-three  the  ascending  frontal,  in  eighteen 
the  ascending  parietal,  in  fourteen  the  superior  parietal, 


Conception  of  Aphasia.  139 

in  thirty-three  the  angular  gyrus,  and  so  on.  In  other 
words,  the  area  of  the  cortex  for  the  representation  of  the 
arm  is  distributed  all  throughout  the  brain  cortex.  Let 
us  contrast  this  for  a  moment  with  the  facts  as  they  really 
exist.  All  clinicians  and  anatomists  are  in  accord  in  allo- 
cating to  the  cortex  of  the  central  lobes,  particularly  the 
ascending  central,  the  representation  for  the  upper  ex- 
tremities. 

Exner's  analysis  of  the  cases  taken  from  the  literature, 
and  studied  by  the  men  who  had  reported  the  cases, 
showed  only  four  instances  in  which  agraphia  had  been 
present.  In  all  of  these,  with  the  exception  of  a  case 
reported  by  Bar1  in  1878,  there  were  multiple  lesions  in 
the  brain.  In  Bar's  case,  the  symptoms  had  been  motor 
aphasia,  agraphia,  and  facial  hemiplegia,  and  the  lesion 
was  localized  in  the  foot  of  the  second  frontal  convolution  ; 
therefore  Exner  posits  this  convolution  as  a  graphic  centre, 
and  by  dint  of  repetition  by  writers  on  aphasia  since  Ex- 
ner's claim  was  first  made  this  fallacy  has  taken  an  almost 
undislodgable  place  in  medical  teachings.  It  seems  to 
have  been  forgotten  that  the  patient  had  motor  aphasia 
and  only  partial  agraphia.  He  could  not  express  his 
thoughts  in  writing,  no  more  could  he  in  speech.  If 
the  lesion  was  of  the  graphic  motor  centre  and  strictly 
confined  to  it,  as  we  are  told  that  it  was,  why  was  the 
agraphia  not  total  and  why  did  the  patient  have  aphasia? 
The  fact  that  he  had  aphasia  is  evidence  enough  that 
there  was  lesion  of  the  zone  of  language  (a  subcortical 
lesion  being  excluded),  and  the  fact  that  he  had  motor 

1  Bar  :  "  Aphasie  et  hemiplegie  faciale  passagere."  La  France  Medicale, 
1876,  p.  609. 


140  The  Faculty  of  Speech. 

aphasia  is  sufficient  explanation  of  the  partial  agraphia. 
The  former  entailed  the  latter.  This  case,  therefore,  instead 
of  lending  itself  to  Exner's  claim,  to  Charcot's  theory,  or 
to  Ziehen's  argument  (not  to  mention  the  scores  of  other 
writers  on  aphasia  who  have  quoted  it  with  the  reverence 
accorded  to  Scripture),  is  unequivocally  opposed  to  them. 

The  ideal  case  to  prove  the  existence  of  a  centre 
whose  function  is  to  store  graphic  images,  and  whose  de- 
struction would  cause  agraphia,  would  be  one  in  which 
there  was  inability  to  write  sponanteously  and  from  dic- 
tation, and  in  which  no  disturbance  of  motility,  partic- 
ularly no  disturbance  of  the  right  upper  extremity,  no 
aphemia,  no  alexia  (that  is,  no  inability  to  read  aloud),  no 
verbal  deafness,  and  no  verbal  blindness  existed.  It  is 
remarkable,  considering  the  zeal  of  physicians  in  ob- 
serving and  reporting  cases  of  aphasia  during  a  period 
which  now  covers  nearly  a  half  of  a  century,  that  no  such 
case  has  been  recorded.  It  is  also  remarkable  that  no 
instance  has  been  reported  in  which  there  was  strict  limi- 
tation of  the  lesion  to  the  second  frontal  convolution,  with 
the  exception  of  Bar's  case,  which  has  been  already 
mentioned. 

Although  clinical  cases  should  not  be  allowed  to  bear 
absolute  testimony  in  favor  of  the  existence  of  a  separate 
centre  for  graphic  motor  images,  when  such  are  unaccom- 
panied by  autopsy,  nevertheless,  a  number  of  clinical  cases 
have  been  reported  in  which  the  evidence,  on  superficial 
examination,  seems  to  point  with  great  certainty  to  the  ex- 
istence of  such  a  centre.  Although  all  of  these  cases  can- 
not be  considered  here,  I  shall  cite  a  few  of  them  to  show 
that  a  different  and  satisfactory  interpretation  can  be  put 


Conception  of  Aphasia.  141 

upon  them,  one  that  does  not  require  the  existence  of 
a  graphic  motor  centre.  A  case  of  this  kind  that  has 
often  been  cited  to  prove  the  existence  of  such  a  centre, 
but  which  has  been  interpreted  by  Dejerine  and  others 
in  an  entirely  different  manner,  is  one  reported  by  Pitres.1 
In  this  case,  Pitres  says,  there  was  no  disturbance  of  in- 
telligence, nor  was  there  paralysis  of  the  right  side.  There 
was  no  trace  of  word  deafness  or  of  word  blindness. 
Nevertheless,  the  patient  was  incapable  of  expressing  a  sin- 
gle thought  by  writing,  and  he  was  quite  as  incapable  of 
writing  from  dictation.  Examination  of  the  patient  nearly 
ten  years  after  the  history  was  first  published  showed  that 
the  conditions  were  practically  unchanged ;  that  is,  that 
still  the  unique  symptom  was  agraphia.  It  therefore 
seemed  probable  to  Pitres  that  this  one  symptom,  per- 
sisting unchanged  for  such  a  long  time,  was  the  result  of 
lesion  of  a  region  of  the  brain  which,  does  not  serve  men- 
tal vision,  nor  yet  phonetic  articulation,  but  which  pre- 
sides uniquely  over  the  motor  excitation  of  writing.  It 
does  not  seem  to  me  that  such  inference  is  at  all  warrant- 
able. In  Pitres'  last  reference  to  this  case  he  has  neg- 
lected to  mention  one  or  two  very  prominent  symptoms, 
whose  importance  is,  I  believe,  vital.  In  the  first  place, 
the  patient  had  hemianopsia,  and,  in  the  second  place,  he 
was  able  to  write  with  the  left  hand.  These  two  facts 
alone  would  seem  to  me  to  stamp  the  case  as  one  of  sen- 
sory agraphia  dependent  upon  a  unilateral  subcortical  le- 
sion that  had  interrupted  the  connection  of  the  area  in 
which  is  stored  the  visual  memory  of  words,  the  angular 
gyrus,  with  the  motor  zone  of  the  left  hemisphere,  leaving 

1  Pitres  :    "  Agraphie  motrice  pure."      Rev.   Med.,  1884,  p.  855. 


142  TJie  Faculty  of  Speech. 

the  connections  with  the  right  hemisphere  intact.  In 
such  event,  the  patient  would  be  unable  to  project  the 
visual  images  of  letters  and  words  which  were  properly 
conserved  to  the  Rolandic-area  cortex  of  the  left  zone, 
but  there  would  be  no  impediment  to  the  passage  of  such 
images  to  the  right  Rolandic  area.  Therefore  the  in- 
ability to  write  with  the  right  hand  would  follow  as  a 
natural  consequence,  likewise  the  ability  to  write  with 
the  left  hand  after  the  latter  had  been  trained  to  writing- 
movements.  Pitres  states  that  the  patient,  on  being  asked 
to  write  the  word  Bordeaux,  said  that  he  could  call  up  in 
the  mind,  that  is,  visualize,  most  distinctly  the  word  Bor- 
deaux, but  he  could  not  write  it,  and  the  author  offers  this 
in  evidence  that  the  inability  to  write  was  not  due  to  loss 
of  visualization  of  words,  but  was  due  to  destruction  of  a 
centre  in  which  are  stored  graphic  motor  images.  To 
quote  the  patient's  own  language,"!  know  very  well, " 
said  he,  "  how  to  write  the  word  Bordeaux,  but  when  I 
wish  to  write  it  with  the  right  hand  I  cannot  make  any- 
thing." This  appears  to  me  to  be  the  keynote  to  the 
interpretation  of  the  case.  The  centre  of  visual  images 
was  intact,  but  the  pathway  by  which  images  travel  to  the 
hand  centre  in  che  Rolandic-area  cortex,  to  be  externalized, 
was  interrupted.  Therefore  he  could  not  write  anything 
with  the  right  hand.  Pitres  very  correctly  says  that  this 
is  quite  different  from  sensory  agraphia,  and  so  it  is  from 
sensory  agraphia  due  to  destruction  of  the  angular  gyrus, 
but  it  is  not  different  from  the  cases  of  agraphia  due  to 
a  subcortical  lesion.  If  there  be  a  centre  in  which  are 
stored  graphic  images  of  words,  it  would  seem  to  me  that 
destruction  of  this  centre  must  entail  complete  agraphia, 


Conception  of  Aphasia.  143 

not  only  for  one  hand,  but  for  the  other,  and  for  any  other 
part  of  the  body  which  may  be  trained  to  hold  the  pen. 
If  this  is  not  so,  then  persons  who  are  capable  of  writing 
as  well  with  the  left  hand  as  with  the  right,  as  I  am,  must 
have  a  separate  graphic  motor  centre  on  each  side  of  the 
brain.  This  does  not  seem  to  be  at  all  in  accord  with 
what  we  know  definitely  of  the  cortical  localization  of 
speech  functions. 

A  second  case  that  has  taken  an  important  place  in 
literature  to  prove  the  existence  of  cortical  motor  agraphia 
is  one  cited  by  Charcot.1  The  patient,  a  Russian  general, 
who  was  able  to  speak  with  facility  in  addition  to  his 
mother  language  both  German  and  French,  suddenly  lost 
the  ability  to  speak  in  either  one  of  these  languages,  al- 
though he  was  still  able  to  understand  them.  After  a 
time  the  capacity  to  speak  French  was  regained,  but  he 
was  never  again  able  to  use  the  German  tongue.  At  no 
time  was  there  any  paralysis,  nor  was  there  any  difficulty 
in  understanding  any  of  these  languages  in  print  or  in 
writing.  The  interpretation  put  upon  this  case  by  Mirallie 
seems  to  me  lucid  and  satisfactory.  The  patient  was  prob- 
ably a  motor  aphasic  for  two  of  the  three  languages  which 
he  had  spoken  fluently,  that  is,  there  was  loss  of  the.  arti- 
culatory  images  of  the  languages  which  he  had  last  ac- 
quired, and  apparently,  they  were  lost,  relatively  to  their 
temporal  acquisition.  The  articulatory  images  of  the 
mother  tongue,  which  every  one  concedes  are  more  in- 
delibly fixed  than  the  images  of  languages  acquired  later 
in  life,  were  not  concerned.  The  motor  aphasia  was, 
therefore,  very  slight,  and  a  considerable  degree  of  re- 

1  Charcot :   "  Lemons  sur  1'aphasie."     Progres  Medical,  1883. 


144  The  Faculty  of  Speech. 

covery  followed.  Careful  examination  of  the  report  of 
the  case  shows  that  the  patient  was  not  totally  agraphic, 
but  that  he  could  write  a  few  letters.  When  he  was 
asked  his  address  he  said,  "  I  reside  at  the  H6tel  de  Bad, 
Boulevard  des  Italiens,"  but  when  he  was  asked  to  put 
his  answer  in  writing  he  was  able  to  write  voluntarily 

only  "  I  re "  and  then  wrote  the  remainder  of  the  word 

from  dictation.  It  is  interesting  to  note  that  the  agraphia 
was  most  complete  for  the  German  language,  less  so  for 
the  French,  and  least  so  for  Russian,  for  he  was  able  to 
write  Charcot's  name  in  the  latter  language  without  much 
difficulty.  If  one  admits  that  there  was  here  a  slight  form 
of  cortical  motor  aphasia  that  had  undergone  .considerable 
amelioration,  that  is,  loss  of  the  articulatory  images  to  a 
slight  degree  for  the  Russian,  and  to  a  very  much  greater 
degree  for  the  French  and  German,  he  must  admit  that 
such  loss  of  images  would  cause  a  disturbance  of  internal 
speech,  and  that  this  disturbance  would  be  manifested  by 
agraphia. 

A  very  similar  interpretation  must  be  put  upon  the  case 
recently  reported  by  Prevost, '  who  cites  a  case  of  Jack- 
sonian  epilepsy  accompanied  by  motor  aphasia  without 
agraphia  to  prove  that  the  former  may  exist  without 
the  latter.  The  patient  was  a  man  sixty  years  old  who 
had  been  neurasthenic  for  a  number  of  years.  A  few 
days  before  he  consulted  Prevost  he  had  remarked  a  con- 
siderable difficulty  of  speech,  particularly  in  finding  ap- 
propriate words.  After  this  the  nervousness  increased ; 
he  complained  of  headache  and  of  a  disagreeable  sensa- 

1  Prevost:     "  Aphasie   motrice   sans   agraphie."     Revue  Medicale  de  la 
Suisse  Romande,  June  2Oth,  1895. 


Conception  of  Aphasia.  \  45 

tion  in  the  right  arm.  Shortly  after  this  there  occurred 
epileptiform  attacks  with  partial  loss  of  consciousness. 
During  these  attacks  he  made  efforts  to  speak,  and  suc- 
ceeded in  uttering  some  unarticulated  sounds  while  he 
grasped  the  chin  with  the  left  hand  and  the  head  was 
turned  convulsively  to  the  right  by  a  series  of  clonic 
convulsions  extending  into  the  right  facial  region  and 
associated  with  conjugate  deviation  of  the  eyes  toward 
the  same  side.  Immediately  after  the  attack,  there  was 
very  pronounced  difficulty  in  speaking.  During  the  next 
few  days  the  patient  had  a  number  of  attacks  in  which 
the  convulsions  extended  to  the  right  arm,  but  spared  the 
right  leg.  On  the  eighth  day  after  the  beginning  of 
the  epileptiform  symptoms  he  became,  immediately  after 
an  attack,  completely  unable  to  speak,  although  it  is 
stated  that  he  understood  perfectly  spoken  and  written 
words,  and  that  writing  was  in  no  way  disturbed.  Con- 
sidering the  fact  that  the  patient  was  not  tested  for  abil- 
ity to  write  from  dictation  and  from  copy,  it  cannot  be 
said  positively  that  writing  was  not  disturbed.  Under 
vigorous  antisyphilitic  treatment,  the  fits  ceased  abruptly 
and  the  ability  to  speak  returned.  Eight  months  later 
the  patient  developed  a  right-sided  hemiplegia.  It  is 
probable  that  in  this  case  the  lesion  was  a  syphilitic  one, 
as  there  was  an  inconclusive  history  of  luetic  infection 
and  the  symptoms  yielded  to  antisyphilitic  treatment,  and 
that  the  first  manifestations  of  the  lesion  were  in  the  lower 
part  of  the  Rolandic-area  cortex ;  that  the  patient  had  a 
subcortical  motor  aphasia,  and  that  the  twitching  in  the 
right  side  of  the  face  and  later  of  the  right  arm  indicated 
an  accession  of  the  lesion  irritating  the  fibres  conducting 


10 


146  The  Faculty  of  Speech. 

motorial  impulses  from  the  cortex  to  these  regions ;  that 
the  syphilitic  vascular  lesion  was  not  an  extensive  one  and 
did  not  destroy  the  area  in  which  it  was  seated.  This 
explanation  would  readily  account  for  the  temporary  loss 
of  speech  following  the  convulsive  attack,  and  for  the 
preservation  of  ability  to  write.  The  fact  that  the  patient 
developed  complete  hemiplegia  a  few  months  later  is  of 
considerable  weight  in  substantiating  this  interpretation 
as  being  one  of  slight  cortical  motor  aphasia  in  the  begin- 
ning, the  lesion  being  one  that  interrupted  the  passage 
of  motor  articulatory  images  to  that  part  of  the  Rolandic 
region  that  starts  the  impulses  to  externalize  them. 

Finally,  a  number  of  cases  must  be  considered,  to  show 
that  there  are  no  real  examples  of  cortical  motor  aphasia 
without  agraphia.  Several  examples  have  been  cited  to 
prove  the  existence  of  such  a  condition,  and  of  these 
the  one  by  Banti '  is  the  best-known.  His  case  was  that 
of  a  man  thirty-six  years  old,  sufficiently  well  educated 
to  read  and  write  correctly,  right-handed,  who  was  sud- 
denly stricken  in  the  street  with  apoplexy,  followed  by 
temporary  loss  of  consciousness.  During  the  following 
night  the  right-sided  hemiplegia  from  which  he  suffered 
almost  entirely  disappeared,  but  the  inability  to  speak 
which  had  come  on  simultaneously  with  the  loss  of  con- 
sciousness still  persisted.  He  was  examined  by  Banti 
on  the  following  day,  who  noted  that  there  was  scarcely 
any  trace  of  paralysis.  On  being  asked  his  name  and 
other  simple  questions,  the  patient  made  futile  efforts  to 
speak,  but  was  unable  to  articulate  a  syllable  or  a  sound. 

1  Banti  :  "  L'aphasie  et  ses  formes."  Lo  Sperimentale,  1886,  vol.  Ivii., 
p.  261. 


Conception  of  Aphasia.  147 

He  chafed  under  this  inability  and  essayed  to  convey  his 
thoughts  by  pantomime.  On  being  given  a  pencil,  he 
wrote  his  name  and  the  answers  to  other  questions,  with 
great  readiness.  Moreover,  on  being  requested  to  give 
an  account  of  his  illness,  he  wrote  a  very  detailed  descrip- 
tion. Writing  from  dictation  and  from  copy  was  also  pos- 
sible, and  the  patient  assured  Banti  that  he  was  able  to 
understand  everything  that  he  wrote,  everything  that  he 
saw  written,  and  everything  that  was  said  to  him.  That 
is,  there  were  no  traces  of  word  blindness  or  of  word 
deafness ;  but  the  inability  to  articulate  was  complete,  al- 
though Banti  states  that  he  wrote  a  number  of  simple 
words  and  endeavored  to  incite  the  patient  to  read  them  in  a 
loud  voice  and  to  say  them  after  him.  Although  the  patient 
observed  with  great  attention  the  movements  of  the  phy- 
sician's lips  and  made  strenuous  efforts  to  obey,  he  was 
never  able  to  pronounce  a  single  word.  Three  years  later 
the  patient  had  entirely  recovered,  the  amelioration  of  the 
aphasia  having  been  a  gradual  one.  After  the  recovery 
was  complete,  it  was  still  noticeable  that  occasionally 
he  slightly  mispronounced  words.  The  patient  died  five 
years  later  of  an  aneurism  of  the  aorta.  In  the  brain 
there  was  found  a  patch  of  yellow  softening  situated  in 
the  posterior  portion  of  the  left  third  frontal  convolution, 
comprising  part  of  the  cortex  situated  between  the  pre-Ro- 
landic  fissure  and  the  anterior  branch  of  the  fissure  of 
Sylvius.  The  author  explicitly  states  that  it  did  not  in- 
volve the  white  substance.  This  case,  which  apparently 
on  first  sight  proves  the  possibility  of  the  occurrence  of 
motor  aphasia  without  concomitant  agraphia,  does  not 
really  do  so.  The  fact  that  the  patient  recovered  the 


148  The  Faculty  of  Speech. 

ability  to  speak  shows  that  all  the  cells  of  Broca's  convo- 
lution could  not  have,  been  destroyed.  Moreover,  the  fact 
that  there  were  no  word  blindness  and  no  auditory  aphasia 
shows  that  the  lesion  of  the  zone  of  language  must  have 
been  slight.  If  particular  information  had  been  given  of 
the  time  and  way  in  which  the  patient  recovered  the 
ability  to  speak,  the  case  would  have  been  very  much  more 
instructive,  for  it  might  be  made  to  bear  testimony  in  be- 
half of  the  assumption  of  speech  function  by  the  unedu- 
cated centre  of  the  opposite  side.  Yet  I  am  inclined  to 
think  that  we  must  admit  that  neighboring  cells  are  ca- 
pable of  taking  up  the  functions  of  destroyed  cells, 
not  only  of  symmetrically  located  ones  but  of  adjacent 
ones.  Such  information  was  not  vouchsafed,  and  there- 
fore the  case  must  be  looked  upon  as  an  inconclusive 
one. 

Kostenitsch  '  has  published  an  observation  of  a  man 
fifty-six  years  old  who  had  a  right-side  hemiplegia  with 
complete  motor  aphasia  of  seventeen  years'  duration,  but 
who  wrote  with  great  ease  with  the  left  hand.  He  avowed 
that  he  could  understand  everything  that  was  said  to  him, 
he  could  sing  melodies  without  the  words,  and  he  could 
read  what  he  had  written.  At  the  autopsy  very  extensive 
lesions  were  found,  particularly  in  the  central  ganglia,  and 
the  whole  left  hemisphere,  more  particularly  the  frontal 
lobes,  was  very  much  atrophied.  The  atrophy  of  Broca's 
convolution  was  especially  well  pronounced.  This  may 
be  considered  an  illustrative  example  of  the  cases  that 
have  been  cited  to  prove  the  existence  of  so-called  motor 

1  Kostenitsch :  "  Ueber  einen  Fall  von  motorischer  Aphasie,"  etc. 
Deutsche  Zeitschrift  fur  Xervenheilkunde,  1893,  vol.  iv. 


Conception  of  Aphasia.  ,      149 

aphasia  without  agraphia.  It  is  an  exact  counterpart  of 
the  case  cited  on  page  201  of  this  monograph,  and  it  is 
susceptible  of  very  similar  interpretation.  The  case 
is,  in  reality,  quite  a  typical  one  of  subcortical  motor 
aphasia,  and  the  report  of  the  autopsy  is  the  most 
conclusive  proof  of  this  contention.  That  the  original 
lesion  was  subcortical  was  shown  by  the  complete  destruc- 
tion in  the  central  masses,  and  to  these  the  atrophy  of  the 
cortical  substance,  a  pure  inactivity  atrophy,  was  due.  The 
microscopical  examination  of  the  cortex,  which  showed 
stunted  cells  and  cells  lacking  in  axones,  is  decidedly 
in  favor  of  this  view. 

In  this  country  a  case  observed  by  Osier1  has  often 
been  cited  in  support  of  a  centre  for  graphic  motor  im- 
ages. A  rfsnmt  of  this  case  is  briefly  as  follows :  An  old 
man  suddenly  developed,  without  paralysis,  inability  to 
read  the  newspaper,  right  lateral  homonymous  hemianop- 
sia,  paraphasia,  and  complete  word  blindness.  On  being 
asked  his  name,  he  was  able  to  pronounce  it,  but  the  al- 
teration of  spontaneous  speech  was  very  manifest  when  he 
attempted  to  tell  his  occupation,  which  was  that  of  book- 
keeper. As  Osier  noted  it,  the  response  to  this  question 
was,  "  Keep,  keep,  keep — oh,  you  say  it  for  me."  In  refer- 
ring to  a  wetting  he  said,  "  Deliberate  attack  of  wet  dress." 
It  was  difficult  to  get  him  to  write  and  it  was  impossible 
for  him  to  write  from  dictation.  He  was  able  to  write  his 
own  name  quite  as  well  with  the  eyes  closed  as  with  them 
open.  He  wrote  the  word  "  Record"  when  told  to  do  so, 

'Osier:  "A  Case  of  Sensory  Aphasia — Word  Blindness  with  Hemi- 
anopsia."  American  Journal  of  the  Medical  Sciences,  Philadelphia,  pp. 
219-224,  1891. 


i  50  The  Faculty  of  Speech. 

but  he  spelled  it  "  Freedom."  These  symptoms  persisted 
two  months,  during  which  time  there  was  gradual  loss  of 
muscular  strength  and  mental  power,  and  finally,  thirty-six 
hours  before  death,  there  was  paralysis  of  the  right  arm 
and  leg.  The  autopsy  showed  necrotic  softening  in  the 
left  hemisphere,  especially  of  the  posterior  part  of  the 
first  and  second  temporal  convolutions  and  of  the  two 
annectant  convolutions  uniting  the  first  temporal  to  the 
parietal  lobe.  There  was  complete  transverse  softening 
of  the  white  matter  between  these  convolutions  externally 
and  the  lateral  ventricle.  Tlie  gray  and  white  matters  of 
the  occipital  lobe  were  uninvohed.  The  softening  in  the 
supramarginal  gyrus  was  more  superficial  than  in  any 
other  portion,  and  it  seemed  to  involve  only  the  gray  mat- 
ter. The  gray  matter  of  the  angular  gyrus  looked  wholly 
normal. 

The  concluding  sentence,  taken  in  connection  with  the 
clinical  history,  makes  it  evident  that  this  was  a  case  of 
subcortical  sensory  aphasia,  the  softening  proceeding  from 
the  deeper  parts  toward  the  periphery.  The  lesion  was 
a  progressive  one  probably,  but  the  patient  died  before 
the  cortex  of  the  angular  gyrus  became  destroyed.  This 
accounts  for  the  writing-capacities  of  the  patient,  as  stated 
by  Osier. 

Charcot  and  Dutil '  put  upon  record  the  case  of  a  wo- 
man, sixty-four  years  old,  who  had  suffered  during  the 
last  twenty  years  of  her  life  four  distinct  attacks  of  apo- 
plexy, after  the  first  of  which  she  was  unable  to  write,  al- 
though there  was  no  speech  disturbance.  Following  on 

'Charcot  and  Dutil:  "  Agraphie  motrice  suivie  d'autopsie."  Mem. 
Societe  Biologic,  1893,  p.  120. 


Conception  of  Aphasia.  151 

a  second  attack,  there  were  added  difficulty  of  speech,  left- 
sided  hemiplegia,  and  eventually  trouble  in  swallowing,  all 
of  which  indicated  a  pseudo-bulbar  palsy.  Although  the 
authors  say  that  the  agraphia  had  all  the  clinical  charac- 
ters of  motor  agraphia,  it  is  to  be  noted  that  all  forms 
of  writing  were  interfered  with.  She  copied  defectively, 
she  wrote  from  dictation  very  badly,  and  was  incapable  of 
writing  spontaneously.  At  the  autopsy  there  were  found 
in  the  right  hemisphere  numerous  small  foci  of.  softening 
and  in  the  left  hemisphere  two  such  foci,  one  of  which 
occupied  the  second  frontal  convolution  and  the  other 
the  inferior  parietal  convolution.  In  reality,  this  case  was 
one  in  which  the  visual  images  were  disordered,  and  the 
patient  was  not  able  to  evocate  them  sufficiently  in  her 
internal  language  to  give  the  complete  idea  of  the  word. 
Instead  of  its  being  a  case  of  motor  agraphia,  the  case 
was  in  reality  one  of  sensory  agraphia,  as  all  the  modalities 
of  writing,  spontaneous  writing,  writing  from  dictation, 
and  writing  from  copy,  were  defective. 

After  taking  all  the  evidence  into  consideration,  of  what- 
ever nature,  that  can  be  cited  in  favor  of  the  existence  of 
a  specialized  graphic  motor  centre,  and  carefully  weighing 
it,  the  conclusion  is  forced  upon  us  that,  so  far,  the  advo- 
cates of  the  existence  of  such  a  centre  have  furnished  us 
with  no  absolute  proof.  It  seems  to  me  entirely  contrary 
to  all  that  we  know  of  speech,  from  a  study  of  its  genesis 
and  its  dissociation,  to  look  for  the  existence  of  such  a 
centre. 

If  claimants  for  the  existence  of  a  graphic  centre  are 
willing  to  admit  that  this  centre  coincides  with  the  allo- 
cation for  the  hand  and  arm  in  the  Rolandic  area  of  the 


152  The  Faculty  of  Speech. 

cortex,  and  that  writing  is  a  hand  motor  function  inner- 
vated from  either  hemisphere,  as  the  case  may  be,  I,  for 
one,  am  inclined  to  agree  with  them.  The  product  that 
writing  externalizes,  however,  is  the  result  of  activity  in  a 
sensory  area,  the  zone  of  language. 


CHAPTER  V. 
MOTOR    APHASIA. 

I.  Motor  Apliasia ;  General  Considerations.  2.  Cortical 
Motor  ApJiasia ;  Articulatory  Kincesthetic  Aphasia. 
J.  Subcortical  Motor  Aphasia. 

THERE  seems  to  be  a  unanimity  of  opinion  among  writers 
on  speech  disorders  in  using  the  term  aphasia  generically 
to  designate  the  disturbances  of  speech  that  result  from  le- 
sion of  the  zone  of  language,  or  of  the  pathways  leading 
to  and  from  the  zone  of  language,  whether  these  relate  to 
its  reception,  its  interpretation,  or  its  emission;  although, 
strictly  speaking,  aphasia  occurs  only  when  there  is  per- 
version of  function  of  the  zone  of  language.  Aphasia  may 
be  classified,  as  I  have  pointed  out  in  another  connection, 
in  a  variety  of  ways.  Disturbance  of  speech  is  manifested 
predominantly  in  its  reception  and  emission,  and  as  the 
reception  of  speech  is  dependent  essentially  on  sensation, 
and  only  in  a  contributory  way  on  motion  (movements  of 
eyes,  ears,  extremities — kinaesthetic  sensation),  the  defect 
in  speech  that  results  from  interference  in  the  reception 
and  interpretation  of  speech  is  called  sensory  aphasia. 
On  the  other  hand,  communication  of  thought  by  speech, 
and,  in  fact,  communication  of  thought  in  any  form,  is 
mediated  through  movement.  For  the  spoken  word  it  is 
by  the  co-ordination  of  the  respiratory  movements,  the 
movements  of  the  vocal  cords,  the  palate,  tongue,  and 


154  The  Faculty  of  Speech. 

lips ;  in  writing,  by  the  movements  of  the  mobile  part  of 
the  body  holding  the  pen  and  acting  under  the  conscious 
or  subconscious  direction  of  the  visual  centre ;  in  the  case 
of  pantomime,  by  movement  of  the  muscles  of  the  face 
and  of  the  extremities.  A  lesion  that  disables  or  mili- 
tates against  externalization  of  speech  is  termed,  in  a 
general  way,  and  principally  for  convenience'  sake,  .motor 
aphasia. 

For  a  number  of  years  after  the  universal  recognition  of 
aphasia  which  followed  on  Broca's  description  of  his  first 
cases  it  was  supposed  that  the  unique  lesion  of  aphasia 
was  in  one  very  definite  part  of  the  brain.  In  the  chap- 
ter on  history  we  have  seen  how  the  labors  of  Wernicke 
and  of  others  disproved  this  when  they  separated  sensory 
aphasia.  Then  for  a  time,  although  it  was  fully  recog- 
nized that  aphasia  was  both  motor  and  sensory,  it  was 
taught  that  motor  aphasia  occurred  only  when  the  gray 
substance  forming  the  foot  of  the  third  frontal  convolu- 
tion, the  seat  of  the  articulatory  kinsesthetic  memories  of 
words,  was  destroyed.  Since  that  time,  however,  a  new 
conception  of  aphasia  has  become  dominant,  and  motor 
aphasia  has  lent  itself  to  subdivision  with  a  readiness 
equal  to  that  of  sensory  aphasia.  And  to-day,  thanks  to 
the  labors  of  Pitres,  Dejerine,  and  other  masters  in  the 
field  of  language,  it  is  possible  to  differentiate  cases  of 
motor  aphasia  according  to  the  seat  of  the  lesion,  whether 
it  be  in  the  articulatory  kinaesthetic  centre,  in  which  are 
preserved  the  phonetic  images,  or  whether  it  be  at  any 
level  of  the  pyramidal  projections  extending  from  the 
Rolandic  area,  where  the  movements  of  respiration,  phona- 
tion,  and  articulation  are  separately  allocated,  down  to  the 


Motor  Aphasia.  155 

pons-oblongata,  where  the  peripheral  neurons  of  these 
pyramidal  tracts  begin.1  Cortical  and  subcortical  motor 
aphasia  are  dependent  upon  anatomical  lesions  which  may 
be  widely  separated.  Clinically,  if  they  are  studied  with 
great  care,  they  can  be  differentiated,  although  it  must 
be  said  that  the  features  which  allow  us  to  distinguish  the 
one  from  the  other  are  not  quite  so  absolute  and  convinc- 
ing as  one  might  be  led  to  infer  from  reading  the  au- 
thors who  have  contended  for  this  differentiation  in  the 
past.  Lichtheim2  averred  that  subcortical  motor  aphasia 
was  characterized  by  the  loss  of  voluntary  speech,  by  ina- 
bility to  repeat  what  was  heard,  by  inability  to  read  aloud, 
by  the  preservation  of  the  comprehension  of  spoken  and 
written  language,  and  by  the  faculty  of  writing  in  all  its 
forms — that  is,  voluntarily,  from  dictation,  and  from  copy. 
Lichtheim  suggested  an  apparently  original  test  for  sub- 
cortical  motor  aphasia  to  prove  that  patients  preserve  the 
memorial  notion  of  the  word ;  that  is,  that  they  have  in 
their  minds  the  name  of  the  object  which  they  are  inca- 
pable of  emitting.  This  test  is  not  infrequently  men- 
tioned in  literature  as  the  Lichtheim  test,  but  Pitres  has 
pointed  out  that  it  was  first  suggested  and  utilized  by 
Proust  in  1872."  Nevertheless,  Lichtheim's  employment 
and  advocacy  of  it  caused  its  general  utilization  and 
acceptation.  As  the  test  is  of  great  importance  in  dif- 
ferentiating cortical  from  subcortical  motor  aphasia,  it 

1 1  desire  to  repeat,  even  at  the  risk  of  tiresome  repetition,  that  in  the 
true  sense  of  the  term  subcortical  motor  aphasia  is  in  reality  not  aphasia 
at  all. 

9  Lichtheim  :  "  Ueber  Aphasie."  Deutsches  Archiv  fiir  klinische  Med., 
1885,  vol.  xxxvi.,  p.  204. 

3  Proust  :   "  De  1'aphasie."     Arch.  Ge'ne'rales  de  Me'decine,  1872. 


156  TJic  Faculty  of  Speech. 

is  necessary  to  be  explicit  concerning  it.  The  patient 
with  cortical  motor  aphasia  is  devoid  of  articulatory 
kinaesthetic  memory  images.  When  he  is  shown  the 
flower  chrysanthemum,  or  when  the  word  chrysanthemum 
is  said  to  him,  he  sees  the  flower  and  he  hears  the  spoken 
word ;  but  when  the  impulses  going  frcm  the  visual  centre 
and  the  auditory  centre  attempt  to  invoke  the  word  chrysan- 
themum in  its  application  to  the  flower  seen  or  to  the  word 
heard  it  cannot  evoke  them  in  his  internal  language,  be- 
cause the  area  of  the  cortex  in  which  articulatory  kinres- 
thetic  memories  are  stored  is  destroyed.  This  perversion 
of  internal  language  is  the  distinguishing  feature  between 
cortical  and  subcortical  motor  aphasia.  Internal  language 
being  disordered  in  cortical  motor  aphasia,  there  is  always 
some  imperfection  in  every  modality  of  internal  language, 
for  it  is  a  law  that  admits  of  no  exception  that  when  one 
of  the  physiological  factors  constituting  or  subserving 
speech  is  impaired  all  manifestations  of  speech  will  be 
disordered,  just  the  same  as  when  one  portion  of  an  intri- 
cate mechanical  device  is  disarranged  it  interferes  with 
the  proper  and  harmonious  working  of  the  whole  appa- 
ratus. This  will  be  the  case  despite  the  fact  that  special 
conditions  may  determine  the  relatively  greater  promi- 
nence in  any  given  consciousness  of  one  element  of  in- 
ternal speech  over  others.  What  these  conditions  may 
be  it  would  be  impracticable,  were  it  not  impossible,  for 
us  to  say.  Psycho-physiologists  have  given  no  clear  ac- 
count of  the  causes  that  determine  the  excitation  of  cor- 
tical nerve  elements  above  the  threshold  of  consciousness. 
To  call  the  phenomenon  a  selective  direction  of  attention 
to  one  of  several  possible  mental  elements,  as  does  Bald- 


Motor  Aphasia.  15; 

win,1  is  only  restating  the    problem  in  terms  somewhat 
less  direct  and  to  me  more  difficult  of  comprehension. 

To  test  this  deficiency  of  internal  language,  Proust  and 
Lichtheim  showed  that  it  sufficed  to  ask  th£  patient  who 
had  heard  some  polysyllabic  word,  such  as  chrysanthe- 
mum, or  had  seen  and  recognized  the  object  indicated  by 
that  word,  to  press  the  interlocutor's  hand  as  many  times 
as  the  word  has  syllables ;  for  instance,  in  the  case  of  the 
word  chrysanthemum,  to  press  it  four  times,  and,  if  not 
by  pressure  of  the  hand,  to  indicate  by  some  movement 
the  number  of  syllables;  then  to  indicate  by  similar 
pressings  the  number  of  letters  in  the  word  and  the  num- 
ber of  letters  in  the  syllables.  It  will  be  readily  seen 
that  this  test  is  merely  the  embodiment  of  the  experience 
that  every  child  has  in  learning  to  talk.  When  a  child 
who  is  learning  to  talk  and  to  read  finds  itself  in  the 
presence  of  a  new  word  it  splits  it  up  into  syllables  and 
pronounces  the  syllables,  if  the  child  is  moderately  ad- 
vanced in  the  acquisition  of  printed  or  written  language ; 
if  it  is  not,  it  splits  the  word  up  into  letters  and  pro- 
nounces each  letter  separately  and  aloud.  If  the  articu- 
lation of  these  words  aloud  (or  even  not  aloud — under 
breath,  as  it  is  called)  calls  up  in  the  mind  by  the  evo- 
cation of  auditory  memories  similar  words  or  objects  or 
qualities  of  objects  for  which  the  word  stands,  the  child 
comprehends.  If  it  does  not,  the  child  has  no  compre- 
hension of  the  word  until  after  it  has  educated  the  articu- 
latory  kinaesthetic  centre  to  associate  the  production  of 
the  word  with  that  which  the  word  stands  for.  The  artic- 
ulatory  centre  becomes  cognizant  of  that  word  by  learn- 

1  "  Mental  Development,"  The  Macmillan  Company,  1896. 


158  The  Faculty  of  Speech, 

ing  the  sounds  of  the  letters  and  syllables  of  which  it  is 
composed,  and  when  this  area  is  destroyed  this  knowledge 
is  lost;  so  that,  when  the  patient  is  asked  to  indicate  by 
sign  or  movement  the  number  of  letters  or  syllables  in  a 
word,  he  is  quite  unable  to  do  so. 

Subcortical  motor  aphasia  spares  the  centre  in  which 
are  seated  the  memories  of  articulation.  The  lesion  in- 
terrupts the  fibres  that  carry  the  speech  impulses  from 
the  cortex,  to  which  they  have  gone  from  Broca's  centre, 
passing  from  the  area  for  the  movements  of  the  lips,  the 
tongue,  the  palate,  the  larynx,  and  the  respiratory  mus- 
cles, at  some  level  of  their  course  before  they  reach  the 
crura.  It  has  been  contended  by  some  writers,  by  Pitres,1 
by  Brissaud,2  by  Juhel-Renoy,  and  Revilliod,  that  such 
lesions  are  not  situated  at  some  indefinite  point,  but  that 
they  are  invariably  situated  at  the  level  of  the  internal 
capsule,  and  that  they  are  never  in  the  so-called  infero- 
pediculo-frontal  fascicle,  adjacent  to  the  cortical  gray  sub- 
stance ;  that  a  lesion  of  the  latter  location  causes  aphasia 
which  does  not  differ  from  pure  cortical  aphasia.  With 
this  last  statement  I  can  in  nowise  agree.  I  have  already 
pointed  out  in  the  chapter  dealing  with  the  genesis  of 
speech  why  this  symptom  complex  is  usually  associated 
with  lesion  very  closely  subjacent  to  the  cortex.  A  lesion 
that  cuts  across  the  axones  of  the  motor  neurons  consti- 
tuting the  pathway  from  the  lip-tongue-laryngeal-respira- 
tory  cortex,  no  matter  where  this  lesion  may  be,  will  pro- 
duce the  clinical  picture  of  subcortical  motor  aphasia,  even 
though  it  be  of  the  very  cell  bodies  of  these  neurons.  On 
the  other  hand,  unless  the  lesion  be  of  the  cells  constitut- 

1  Loc.  cit,          *  Article  "  Aphasie."     "  Traite  de  Medecine,"  vol.  vi. 


Motor  Aphasia. 

ing  the  articulatory  kimesthetic  centre  and  their  axones, 
which  I  believe  to  be  entirely  association  tracts  and  not 
at  all  projection  tracts,  the  features  of  the  aphasia  will 
not  be  those  of  cortical  motor  aphasia.  Nevertheless,  I 
frankly  admit  that  it  is  very  much  more  difficult  to  make 
a  diagnosis  of  subcortical  motor  aphasia  when  the  lesion 
is  situated  contiguous  to  Broca's  centre  than  when  it  is 
situated  at  some  distance.  It  must  be  kept  in  mind,  how- 
ever, that  it  is  not  easy  in  any  instance  to  make  during 
life  a  diagnosis  differentiating  between  cortical  and  sub- 
cortical  motor  aphasia.  The  truth  is  that  the  Proust- 
Lichtheim  test  is  not  very  readily  applied,  because  many 
of  the  patients  with  whom  we  have  to  deal  are  quite  inca- 
pable of  comprehending  what  we  are  striving  for  when  we 
endeavor  to  utilize  it  and  what  we  wish  them  to  do ;  but 
when  it  can  be  applied  it  is  a  test  of  great  value. 

The  most  striking  picture  of  cortical  motor  aphasia  is 
the  loss  of  speech,  articulate  or  non-articulate,  which  is 
manifest  on  attempting  to  make  voluntary  communica- 
tions, on  attempting  to  repeat  what  is  heard,  and  on  at- 
tempting to  read  aloud.  If  the  lesion  is  closely  restricted 
to  Broca's  convolution,  these  are  the  leading  features  of 
the  aphasia.  The  patient  understands  all  that  is  said  to 
him ;  he  gets  the  proper  apperception  of  visual  objects 
which  leads  to  the  formation  of  concepts;  he  receives 
trustworthy  information  from  other  sources  on  which  he 
has  been  accustomed  to  rely  for  information,  at  first  hand 
or  for  corroboration,  and  they  in  turn  endeavor  to  invoke 
the  images  of  articulate  speech,  which  images  normal  man 
utilizes  in  intercourse  with  his  fellows  and  which  many 
persons,  particularly  the  illiterate,  use  in  thought.  The 


160  The  Faculty  of  SpeecJi. 

area  of  the  cortex  in  which  such  images  of  articulative 
speech  are  stored  is  destroyed,  and  as  the  result  of  its 
destruction  its  function  is  abolished.  The  lesion  that 
causes  motor  aphasia  is  in  the  great  majority  of  the  cases 
a  vascular  one,  and  as  the  same  blood-vessel,  the  left  mid- 
dle cerebral,  is  the  principal  medium  of  arterial  supply  for 
the  remainder  of  the  speech  area,  it  is  only  in  exceptional 
instances  that  destruction  of  Broca's  convolution  is  not 
accompanied  by  some  anatomical  perversion  of  other  parts 
of  the  zone  of  language,  although  these  are  usually  transi- 
tory. There  is  invariably  some  perversion  of  function  of 
the  other  speech  centres,  because  perfect  speech  demands 
the  harmonious  co-operation  of  all  the  speech  centres,  and 
one  cannot  be  disordered  without  entailing  derangement 
of  all. 

Cortical  Motor  Aphasia.      Articulatory  Kincesthetic 
Aphasia. 

By  cortical  motor  aphasia  I  mean  a  disturbance  of 
speech  due  to  loss  of  the  sensory  images  of  articulation 
associated  with  loss  of  the  sensory  memories  of  co-ordi- 
nate movements  entering  into  vocal  expression ;  the  latter 
is  not  essential,  but  it  is  an  accompaniment  in  nearly  every 
instance.  Cortical  motor  aphasia  is  characterized  partic- 
ularly by  a  loss  of  spontaneous  and  repeated  speech  and 
by  the  preservation  of  the  capacity  to  comprehend  spoken 
speech.  The  peripheral  speech  mechanism — the  tongue, 
lips,  palate,  and  vocal  cords — is  in  condition  to  function- 
ate. The  only  justification  for  the  use  of  the  word  motor 
in  this,  form  of  aphasia  is  that  the  images  of  articulation 
are  called  into  being  by  movement  and  are  externalized  by 


Motor  Aphasia.  161 

movement^  Therefore  in  true  cortical  motor  aphasia  there 
exists  the  same  inability  to  call  into  being  the  sensory  mem- 
ories of  articulation,  and  thus  to  make  them  a  part  of  in- 
ternal speech,  as  there  is  to  externalize  them  in  the  shape 
of  articulate  words.  Many  of  the  cases  of  aphasia  in  the 
literature  which  are  considered  to  belong  in  this  category 
are  not  of  this  variety  at  all,  but  are  examples  of  pure 
motor  aphasia  (of  Dejerine),  or  subcortical  motor  aphasia; 
that  is,  disturbance  of  speech  dependent  upon  interruption 
of  the  projection  tracts  which  convey  the  articulatory  im- 
pulses from  the  cortical  area  of  the  peripheral  speech  mech- 
anism to  the  peripheral  speech  apparatus.  In  fact,  not 
much  more  than  one-half  the  reported  cases  have  been 
studied  with  sufficient  care  to  warrant  including  them  in 
this  category.  And  this  is  so  for  many  reasons.  In  the 
first  place,  the  centres  of  the  speech  area  in  which  are 
stored  definite  memories  are  rarely  involved  alone.  In 
the  great  majority  of  instances  the  lesion  is  of  vascular 
origin,  and  the  nutritive  supply  of  one  centre  or  the  struc- 
ture of  the  centre  itself  is  not  perverted  without  a  ma- 
terial disturbance  of  function  in  some  of  the  other  centres. 
And  in  the  second  place,  it  is  only  within  recent  times 
that  the  possibility  of,  and  the  necessity  for,  differentiating 
this  form  of  motor  aphasia  from  the  subcortical  form  has 
been  generally  understood.  The  motor  area  of  the  brain 
should  be,  as  I  have  said  before,  limited  to  that  part  of  the 
brain  from  which  the  motor  projection  system  of  fibres 
passes,  and  there  is  no  unassailable  evidence  to  show  that 
the  inferior  frontal  fascicle,  which  has  been  allotted  as  the 
system  of  projection  fibres  extending  from  Broca's  convo- 
lution, has  anything  to  do  with  this  purpose.  Until  within 


1 62  The  Faculty  of  Speech. 

a  very  recent  time,  motor  aphasia,  which  was  described  by 
Broca  as  true  aphasia  or  aphemia,  by  Wernicke  as  motor 
aphasia,  and  by  Kussmaul  as  ataxic  aphasia,  was  supposed 
to  be  fully  understood  and  most  thoroughly  established 
on  an  anatomical  foundation.  But  the  writings  of  De- 
jerine  and  his  pupils,  of  Wyllie,  of  Elder,  of  Onuf,  and 
of  others,  and  the  labors  of  the  physiologists,  particularly 
Horsley,  Krause,  Masini,  and  Semon,  have  shown  the 
necessity  of  rewriting  the  chapter  on  motor  aphasia  and 
emancipating  it  from  the  dicta  of  the  older  writers. 

As  a  case  of  cortical  motor  aphasia  in  which  the  symp- 
toms indicated  that  the  lesion  was  very  closely  limited  to 
Broca's  convolution,  the  seat  of  articulatory-kinaesthetic 
images,  I  may  cite  the  following : 

A  young  man,  thirty-two  years  of  age,  was  admitted  to 
my  wards  in  the  City  Hospital,  suffering  from  an  incom- 
plete right-side  hemiplegia.  His  history  antecedent  to 
the  attack,  which  had  occurred  five  months  previously,  is  of 
no  interest,  except  that  he  had  had  two  attacks  of  inflamma- 
tory rheumatism.  After  the  apoplectic  stroke,  which  came 
suddenly  in  the  night  and  which  was  followed  by  loss  of 
consciousness,  he  was  unable  to  talk,  and  this  condition 
obtained  when  he  entered  the  hospital.  The  apoplectic 
stroke  was  considered  to  be  of  embolic  origin,  as  exami- 
nation of  the  heart  showed  well-marked  incompetence  of 
the  aortic  valves.  Investigation  of  the  speech  defect 
showed  that  he  was  unable  to  communicate  his  thoughts 
by  spoken  words,  that  he  was  unable  to  repeat  from  dicta- 
tion ;  that  he  was  unable  to  write,  save  his  name,  and  that 
very  slowly  and  laboriously  with  the  left  hand ;  and  that 
he  was  unable  to  indicate  the  number  of  syllables  in  a 
word  previously  seen  or  heard,  by  pressing  his  interlocu- 


Motor  Aphasia.  163 

tor's  hand  as  many  times  as  there  were  syllables.  He  in- 
terpreted quickly  and  easily  everything  that  was  said  to 
him,  but  he  could  not  write  from  dictation.  There  was  no 
trace  of  word  blindness  or  of  letter  blindness,  and  he  cop- 
ied letters  and  words  correctly.  On  account  of  the  paral- 
ysis of  his  right  arm,  he  was  not  able  to  copy  quickly,  but 
if  he  was  given  sufficient  time  he  showed  that  he  was 
quite  capable  of  doing  this.  When  he  was  given  a  para- 
graph in  a  newspaper  and  asked  to  copy  it,  he  copied  it 
in  writing.  The  patient  was  able  to  read  and  apparently 
to  comprehend  what  he  read,  but  he  never  took  any  inter- 
est in  the  newspapers,  nor  was  he  seen  to  read  anything 
spontaneously  during  his  stay  in  the  hospital.  That  he 
comprehended  written  and  printed  requests,  however,  was 
shown  by  the  readiness  with  which  he  obeyed  requests 
when  they  were  communicated  to  him  in  this  way.  The 
patient  remained  in  the  hospital  but  a  short  time,  and 
only  one  opportunity  was  had  to  test  his  ability  to  write 
by  means  of  individual  letters.  On  this  occasion  a  num- 
ber of  each  of  the  letters  of  the  alphabet  were  put  before 
him  on  the  table  and  he  was  requested  to  construct  the 
sentence,  "The  President  of  the  United  States  is  inaugu- 
rated on  the  4th  day  of  March."  This  sentence  was  com- 
pleted after  the  expenditure  of  a  considerable  time,  and, 
save  for  two  or  three  mistakes  in  spelling,  it  was  correctly 
done. 

This  brief  rehearsal  of  the  symptoms  in  this  case  shows 
that  the  speech  defect  was,  strikingly,  loss  of  the  sensory 
images  of  articulation.  The  patient,  though  in  full  pos- 
session of  the  avenues  by  which  one  receives  stimuli,  au- 
ditory, visual,  and  kinaesthetic,  necessary  to  speech  pro- 
duction, was  unable  to  speak  any  words  except  "  Yes"  and 
"  No,"  the  former  of  which  was  enunciated  most  indis- 


164  The  Faculty  of  Speech. 

tinctly.  That  this  loss  of  power  of  articulation  was  de- 
pendent upon  lesion  in  the  zone  of  language  and  not  upon 
the  projection  tract  of  pyramidal  fibres  is  shown  conclu- 
sively by  the  fact  that  the  patient  could  not  call  up  the 
articulatory  kinaesthetic  memories  of  words.  For  in  every 
instance  when  he  was  tested  in  this  way  he  failed  to  indi- 
cate by  pressing  the  hand  or  by  holding  up  the  fingers  the 
number  of  syllables  in  the  word  desired. 

From  this  it  will  be  seen  that  the  essential  accompani- 
ment of  cortical  motor  aphasia  is :  loss  of  spontaneous 
speech,  due  to  a  destruction  of  the  sensory  images  of  artic- 
ulation stored  up  in  the  foot  of  the  third  frontal  convolu- 
tion. Associated  with  this  loss  of  spontaneous  speech 
there  is  a  loss  of  all  forms  of  speech  utterance  for  which 
an  evocation  of  articulatory  kinaesthetic  memories  is  re- 
quired. Therefore  there  are  inability  to  repeat  words  and 
inability  to  read  aloud,  but  the  patient  comprehends  spoken 
words,  oftentimes  somewhat  imperfectly.  There  is  inabil- 
ity to  express  thoughts  in  writing,  because  in  writing  the 
motor  word  representations  are  always  revived  by  the  im- 
pulse which  travels  from  the  percipient  centre  (which  is 
either  in  the  visual  area  of  the  brain  in  spontaneous  writ- 
ing, or  in  the  auditory  speech  area  in  writing  from  dicta- 
tion) through  the  articulatory  kinaesthetic  centre  to  that 
part  of  the  Rolandic  region  which  guides  the  mobile  part 
of  the  body  holding  the  pen.  On  account  of  the  onto- 
genetic  intimacy  existing  between  the  receptive  speech 
centres  and  the  emissive,  disturbance  of  the  emissive 
speech  centre  almost  invariably  produces  some  disturb- 
ance which  is  manifest  through  the  former.  This  is 
shown  in  cortical  motor  aphasia  by  difficulty  in  calling 


Motor  Aphasia.  165 

up  promptly  and  with  readiness  auditory  word  images  to 
which  articulatory  kinaesthetic  images  are  subservient,  and 
in  some  degree  by  a  disturbance  of  internal  reading.  In 
the  great  majority  of  people  it  is  probable  that  reading 
to  one's  self  is  accomplished  by  evoking  the  images  of 
articulation,  and  that  as  a  matter  of  education,  of  expedi- 
ency, a  short  cut  is  established  between  the  area  in  which 
visual  images  are  stored  and  the  association  tracts  con- 
stituting the  anatomical  basis  of  comprehension. 

In  cortical  motor  aphasia  there  is  sometimes  very  com- 
plete amimia.  This  is  to  be  explained  by  the  fact  that 
studied  pantomime  is  associated  normally  with  arousal  of 
the  images  of  articulation. 

If  destruction  of  Broca's  area  is  total,  or  nearly  so, 
the  capacity  for  articulate  speech  will  be  correspondingly 
complete ;  while  if  the  convolution  of  Broca  be  only 
partially  destroyed,  and  particularly  if  the  lesion  be  a 
vascular  one,  such  as  plugging  of  the  branch  of  the  middle 
cerebral  artery  that  suplies  Broca's  convolution,  with  sub- 
sequent exudation,  a  reparative  process  may  set  in.  Then 
the  degree  of  the  completeness  of  the  aphasia  bears  some 
relation,  though  just  how  much  cannot  be  said,  to  the 
amount  of  repossession  of  articulated  images.  It  seems 
to  me  that  this  offers  quite  as  satisfactory  explanation  of 
the  possession  of  certain  words  or  the  acquisition  of  a  few 
words  by  patients  who  have  a  lesion  of  Broca's  centre  as 
does  the  view  that  attributes  such  partial  recovery  of  speech 
to  the  vicarious  assumption  of  function  by  the  so-called 
uneducated  centre  of  the  opposite  side,  of  which  so  much 
has  been  made  by  many  writers  in  accounting  for  recov- 
eries and  for  the  utility  of  certain  modes  of  treatment.  I 


1 66  The  Faculty  of  Speech. 

hasten  to  say  that  I  do  not  deny  that  the  corresponding 
centre  of  the  other  side,  although  not  ontogenetically 
intended  for  speech,  may  and  does  take  up  in  a  crude  com- 
pensatory way  the  function  of  the  speech  area.  This  sub- 
ject will  be  referred  to  again,  in  the  chapter  on  "Treat- 
ment." Nevertheless,  I  believe  that  it  never  does  so  except 
by  process  of  education ;  it  does  not  seem  to  me  that  there 
is  any  spontaneous  assumption  of  function.  Naturally,  I 
cannot  offer  any  tangible  or  incontrovertible  evidence  in 
support  of  this  belief,  but  here  my  position  is  not  very  dif- 
ferent from  that  of  those  who  hold  to  spontaneous  assump- 
tion of  speech  function  by  the  uneducated  side.  They  cite 
in  support  of  their  contention  cases  which  I  believe  to  be 
typical  examples  of  subcortical  motor  aphasia.  Such  a 
case  has  been  reported  by  Wyllie :' 

A  young  man  developed  a  right-sided  hemiplegia,  prob- 
ably of  thrombotic  origin.  The  attack  came  on  gradu- 
ally and  in  successive  stages.  At  first  he  was  completely 
speechless,  but  soon  regained  ability  to  say  "  Yes"  and 
"  No"  and  to  answer  questions  in  writing.  "  He  states  that 
he  never  from  the  first  had  any  difficulty  in  calling  up  in 
Jiis  mind  the  words  that  he  wished  to  write"  (italics  mine). 
This,  it  seems  to  me,  stamps  the  case  as  one  of  aphasia  due 
to  lesion  outside  the  zone  of  language.  If  there  was  no 
other  evidence  than  this,  it  would  be  sufficient  to  convince 
me  that  he  had  likewise  no  difficulty  in  calling  up  the  words 
that  he  wished  to  utter,  for  people  of  his  education  usually 
spell  words  articulately  when  writing  them.  But  witness 
testimony  to  this  effect  from  the  patient :  "  With  regard  to 
my  forming  words  in  my  mind,  i  could  always  form  them  in 

1  Wyllie  :   "  The  Disorders  of  Speech,"  Edinburgh,  1894,  p   323. 


Motor  Aphasia.  167 

my  mind  but  trc  ible  was  in  getting  them  out.  i  could  not 
get  them  out  at  all  and  after  making  all  the  signs  i  could 
think  of  to  my  friends  if  they  could  not  understand  me  i 
would  have  to  take  paper  and  pencil  and  write  it  down  for 
them." 

This,  I  venture  to  believe,  is  conclusive  evidence  that 
the  patient  had  no  defect  of  internal  language,  such  as 
invariably  accompanies  destruction  of  the  articulatory 
kinaesthetic  images  in  Broca's  area.  The  patient  recov- 
ered the  use  of  the  paralyzed  side,  and  consequently  it  ex- 
cites no  astonishment  in  me  that  he  recovered  the  power 
to  externalize  speech  commensurably  with  this ;  nor  can  I 
for  a  moment  consider  it  an  example  which  goes  to  show 
how  "  the  previously  uneducated  centre  educates  itself." 
Moreover,  it  does  not  seem  to  me  that  the  case  is  remark- 
able, "  inasmuch  as  it  is  one  of  that  comparatively  rare 
variety  in  which  the  patient,  utterly  aphasic  as  to  spoken 
speech,  is  yet  capable  of  expressing  himself  in  writing." 
I  shall  hope  to  show  in  this  chapter  that  subcortical 
aphasia  is  not  rare,  and  that  it  is  characterized  by  the  re- 
tention of  the  capacity  on  the  part  of  the  patient  to  express 
himself  in  writing. 

There  are  on  record  a  number  of  cases  which  illustrate 
a  partial  destruction  of  Broca's  area  with  preservation  of 
the  ability  to  write  and  repossession  of  the  ability  to  speak. 
Of  such  cases  the  most  remarkable  is  one  recorded  by 
Banti.1 

This  patient,  a  man  thirty-six  years  of  age,  right-handed, 
capable  of  reading  and  writing,  was  stricken  suddenly 
with  an  attack  of  apoplexy,  while  walking  the  street,  fol- 

1  Banti  :  Sperimentale,  Firenze,  1886. 


1 68  The  Faculty  of  Speech. 

lowed  by  loss  of  consciousness.  Consciousness  returned 
after  a  few  minutes,  but  he  was  paralyzed  in  the  right 
arm  and  right  leg  and  was  wholly  unable  to  speak.  The 
hemiplegia  disappeared  almost  completely  during  the  fol- 
lowing night,  but  the  inability  to  speak  still  continued. 
On  the  following  day  he  was  admitted  to  the  hospital  and 
there  examined  by  Banti,  who  noted  that  the  motility  of 
the  extremities  was  normal  and  that  there  was  no  trace 
of  paralysis  of  the  face  or  of  the  tongue.  The  patient 
made  futile  efforts  to  speak,  but  he  was  incapable  of  artic- 
ulating a  word  or  a  syllable.  He  chafed  exceedingly 
under  this  mutism  and  sought  to  convey  his  meaning  by 
gestures.  On  being  asked  if  he  could  write,  he  made  a 
gesture  of  affirmation,  and  on  being  given  a  pencil  imme- 
diately wrote  his  name.  To  numerous  other  questions  he 
responded  with  accuracy  in  writing,  and  without  hesitation 
wrote  a  detailed  account  of  his  disease  when  he  was  re- 
quested to  do  so.  He  wrote  also  the  names  of  objects 
that  were  shown  to  him,  and  of  objects  whose  qualities 
he  heard.  He  answered  questions  that  were  asked  in 
writing  with  perfect  precision.  He  comprehended  script 
and  print  equally  well,  seized  the  sense  of  a  question  very 
quickly,  and  wrote  rapidly  and  without  the  slightest  hesi- 
tation. But  he  was  unable  to  pronounce  or  articulate  a 
word.  The  aphasia  ameliorated  gradually,  so  that  in  less 
than  three  years  he  was  able  to  express  himself  freely. 
Nevertheless,  attentive  examination  showed  slight  defects 
of  articulate  speech.  Five  years  later  the  patient  died 
of  an  aneurism  of  the  aorta ;  and  on  autopsy  there  was 
found  a  patch  of  yellow  softening  situated  in  the  posterior 
portion  of  the  third  left  frontal  convolution,  and  separated 


Motor  Aphasia.  169 

from  the  white  substance  by  a  portion  of  tissue  only  a  few 
millimetres  in  thickness.  In  this  case  it  does  not  seem  to 
me  that  there  can  be  much  doubt  that  a  part  of  the  area  in 
which  are  stored  the  images  of  articulation  was  undestroyed. 
In  no  other  way  can  be  satisfactorily  explained  the  re- 
markable degree  of  preservation  of  writing-capacity  and 
the  rapidity  with  which  he  regained  speech  possession. 

It  is  more  than  likely  that  our  attention  has  been  cen- 
tred too  exclusively  on  the  unilateral  representation  of  the 
speech  faculty.  It  is  possible  that  the  right  side  of  the 
brain  contains  appercipient  speech  centres  which  are  in 
direct  anatomical  and  physiological  association  by  means 
of  the  fibres  of  the  corpus  callosum.  The  apperceptive 
centres  of  the  right  side  of  the  brain  do  not,  however, 
constitute  an  autonomy,  nor  do  they  seem  to  have  any 
effect  in  determining  the  execution  of  speech  functions. 
Therefore  when  the  right  hemisphere  is  the  seat  of  lesion 
in  right-handed  persons,  there  is  no  trouble  in  the  execu- 
tion of  speech.  The  influence  that  has  most  to  do  with 
determining  the  superiority  of  the  left  hemisphere  as  the 
speech  side  of  the  brain,  after  ontogenetic  influences,  is 
education.  Just  what  the  antecedent  factors  are  in  this 
determination  it  is  impossible  to  say.  The  general  speech 
education,  so  to  say,  that  the  opposite  hemisphere  receives 
has  much  to  do  with  the  possibility  of  educating  it  to 
compensate  in  part  for  destroyed  centres  of  the  zone  of 
language. 

The  capacity  for  articulate  expression  which  a  few,  com- 
pared with  the  entire  number  of  motor  aphasics,  retain  is 
for  a  few  words  whose  utterance  partakes  more  of  the  na- 
ture of  a  reflex  act  or  of  an'  emotional  possession  than  it 


i  70  The  Faculty  of  Speech. 

does  of  a  process  of  intellection.  They  consist  of  "  Yes" 
or  "  No,"  the  patient's  name  or  address ;  possessions  which 
from  long  usage  signify  one  definite  purpose  or  thing  and 
are  uttered  nearly  reflexly.  In  like  manner,  they  some- 
times retain  the  capacity  to  use  conventional  expressions, 
such  as  "Good  morning,"  "How  are  you?"  "Very  fine," 
etc.,  and  these  they  employ  for  every  occasion,  pertinent 
and  non-pertinent  alike.  Oftentimes  these  expressions  are 
used  by  the  patient  in  a  way  that  reminds  one  of  an  echo. 
Whether  such  reflex  or  echo-like  words  cannot  be  pro- 
duced by  the  action  of  sensory  impulses  directly  on  the 
central  executive  motor  speech  mechanism,  I  have  often 
debated.  The  answers  that  such  patients  give  are  com- 
parable to  the  speech  of  a  parrot,  and  no  one  believes 
that  a  parrot  has  an  ontogenetic  speech  centre  for  memory 
images  of  articulation.  Sensory  excitations  call  forth  uni- 
form responses  in  the  parrot  with  tiresome  monotony,  and 
it  is  the  same  way  in  the  patients ;  they  may  respond  "  Tan, 
tan,"  or  "  Yi,  yi,"  or  "  Yes"  to  everything.  Echoing  or 
echolalia  in  cortical  motor  aphasia  is  a  phenomenon  that 
is  occasionally  present,  oftenest  when  the  patient  is  recov- 
ering. The  occurrence  of  echolalia  has  been  thought  to 
indicate  the  assumption  of  function  by  the  uneducated 
side.  The  patient  repeats  a  word  which  he  has  heard,  or 
a  sound,  in  the  same  senseless  fashion  and  with  the  same 
tireless  persistency  that  a  child  does  who  is  learning  to 
talk.  It  may  possibly  be  an  indication  of  the  functioning 
of  a  centre  on  the  right  side  of  the  brain  which  is  not  yet 
fully  under  control,  inhibitory  or  exciting,  of  the  sensory 
apperceptive  centres.  On  the  other  hand,  it  may  be  the 
manifestation  of  a  certain  retention  of  function  by  the  dis- 


Motor  Aphasia.  \  7 1 

eased  area.  The  disorganization  of  Broca's  convolution 
being  sufficient  to  rob  it  of  all  purposive  activity,  it  retains 
a  semblance  of  function  pointing  to  what  it  once  was. 

Another  very  striking  variety  of  articulate  speech  which 
patients  with  motor  aphasia  show  is  that  to  which  the 
term  lalling  or  lallation  is  applied.  The  significance  of 
the  term,  "  baby  talk,"  is  indicated  by  its  derivation.  It, 
like  its  congeners,  stammering  and  dysarthria,  is  a  symp- 
tom of  subcortical  motor  aphasia,  and  rarely  of  the  cortical 
variety. 

The  degree  of  completeness  of  the  loss  of  articulate 
speech  is,  as  has  been  said,  a  variable  quantity.  Al- 
though in  cortical  motor  aphasia  the  power  to  make  vol- 
untary expression  is  usually  entirely  gone,  the  loss  may 
be  partial,  nearly  all  words  or  only  a  certain  class  of  words 
having  perished.  When  partial,  the  power  of  expression 
is  limited,  as  a  rule,  to  one  or  more  monosyllabic  words, 
which  the  patient  may  use  intelligently  but  which  are  not 
infrequently  used  in  answer  to  every  question — for  in- 
stance, the  word  "  No"  to  express  negation  and  assent 
alike.  In  other  cases,  the  ability  to  articulate  certain 
vowel  sounds,  such  as  a,  o,  11,  or  some  of  the  consonants, 
may  be  preserved.  Occasionally,  patients  who  are  afflicted 
with  complete  motor  aphasia  are  able  to  utter  some  words 
of  the  nature  of  an  oath,  which  seem  to  escape  from  them 
in  a  rapid,  uncontrollable  way,  or  to  ejaculate  words  ex- 
pressive of  the  feelings.  Such  expresions  are  not  the 
product  of  cognition,  but  of  the  emotions,  and  partake  of 
the  nature  of  reflex  action.  Other  patients  repeat  con- 
tinually some  expressive  -or  meaningless  word  or  words. 
These  repeated  words  or  sentences,  though  often  of  no 


1 72  The  Faculty  of  Speech. 

pertinency,  seem  occasionally  to  have  a  definite  meaning, 
in  so  much  as  they  are  connected  with  the  onset  of  the 
patient's  disease.  Thus,  a  patient  who  had  complete 
motor  aphasia,  observed  by  Hughlings  Jackson,  kept  re- 
peating, "  I  want  protection. "  The  man  had  received  a 
serious  injury  of  the  head  during  a  quarrel,  and  it  has 
been  suggested  that  in  such  a  case  (there  are  many  of 
them  on  record)  the  frequently  repeated  word  or  phrase 
was  the  last  one  uttered  by  the  patient  before  he  became 
aphasic,  and  that  these  words,  the  last  enregistered  in  the 
centre  of  articulatory  memories,  are  the  ones  most  promptly 
evoked  when  sensory  impressions  reach  it. 

Such  recurring  utterances  are  distinctive  features  of 
cortical  motor  aphasia,  and  not  of  the  subcortical  variety, 
for  the  latter  really  is  a  shortcoming  of  articulation,  and 
if  articulation  is  not  wholly  impossible  the  defect  is  man- 
ifest by  some  variation  in  the  perfectness  with  which  the 
word  is  produced. 

In  the  ordinary  case  of  motor  aphasia,  although  the 
emotional  faculties  are  often  disturbed,  the  patient  is 
capable  of  giving  spontaneous  expression  to  his  feelings 
when  such  expression  does  not  require  the  use  of  words. 
The  patient's  intellectual  faculties  do  not  on  casual  exam- 
ination seem  to  be  materially  impaired,  although  there  is 
usually  an  indisposition  or  lack  of  readiness  on  the  part 
of  the  patient  to  indulge  in  anything  requiring  mental 
application.  On  that  score  cortical  motor  aphasia  differs 
most  materially  from  subcortical  forms.  Patients  with 
the  latter  are  as  ready  and  willing  and  capacious  to  at- 
tack mental  problems  as  normal  man,  and  not  infrequently 
transact  business  calling  for  great  mental  integrity  and 


Motor  Aphasia.  173 

indulge  in  games  requiring  profound  abstraction,  such  as 
chess.  Patients  with  cortical  motor  aphasia  often  show 
great  amnesia  and  lack  of  comprehensive  grasp  of  facts 
that  have  been  communicated  to  them  since  their  illness. 
This  is  easy  of  interpretation  if  it  be  borne  in  mind  that 
lesion  of  Broca's  area  entails  perversion  of  the  function  of 
internal  language.  He  has  lost  the  ability  to  repeat  in- 
wardly what  is  said  to  him,  what  he  hears ;  and  as  most 
people  obtain  knowledge  for  storing  up  in  this  way,  the 
person  with  true  motor  aphasia  is  deprived  of  the  power 
of  thus  laying  up  knowledge.  This,  combined  with  the 
dyslexia  or  alexia  which  unfits  him  for  obtaining  knowl- 
edge by  reading,  is  abundant  explanation  of  the  amnesia. 
Cortical  motor  aphasia  is  sometimes  manifest  merely 
by  a  loss  of  substantives ;  amnesia  of  the  names  of  the 
things  or  objects  of  which  the  patient  tries  to  speak. 
For  instance,  a  patient  who  wishes  to  request  some- 
thing may  be  able  to  produce  every  word  except  the  one 
which  is  the  embodiment  of  his  request.  A  patient 

of  Trousseau  would  say,    "  Give  me  my — u — u sacrt 

matin."  "Your  umbrella?"  "Yes,  my  umbrella."  It 
seems  to  me  very  questionable,  however,  that  this  is  a 
genuine  example  of  amnesia  of  the  articulatory  memories 
for  substantives,  and  the  fact  that  he  was  able  to  say  the 
first  letter  of  the  word  in  the  name  of  the  desired  object 
is  rather  in  favor  of  its  being  a  case  of  subcortical  motor 
aphasia,  the  stumbling  and  stammering  being  apparent 
when  he  attempted  to  utter  particular  names.  A  much  more 
convincing  example  of  the  loss  of  the  articulatory  memory 
of  substantives  is  furnished  by  a  patient  who,  knowing 
just  what  he  wants,  instead  of  saying,  "Give  me  my 


i  74  The  Faculty  of  Speech. 

watch,"  says,  "  Give  me  what  I  tell  the  time  with,"  or 
who  calls  a  knife  "  something  to  cut  with,"  and  so  on. 
In  these  cases  the  amnesia  for  substantives  may  be  the 
only  aphasic  symptom.  Very  much  less  common  is  artic- 
ulative  amnesia  of  verbs,  the  ability  to  use  substantives 
being  preserved.  When  it  is  recalled  how  very  much 
more  complex  the  formation  of  a  mental  percept  of  a 
name  is  than  that  of  an  object,  and  how  much  easier  it  is 
to  recall  the  qualities,  capabilities,  and  possessions  of  ob- 
jects than  the  name  of  such  an  object,  it  will  be  under- 
stood that  articulatory  amnesia  of  substantives  is  much 
more  common  than  articulatory  amnesia  of  verbs. 

The  retention  of  speech  capacity  that  patients  with  artic- 
ulatory kinaesthetic  aphasia  sometimes  have  is  very  sur- 
prising. In  addition  to  the  form  of  which  I  have  just 
spoken,  in  which  the  speech  defect  is  confined  to  loss  of 
substantives,  others  are  occasionally  observed  in  which 
the  patient  is  unable  to  repeat  any  words  except  to  count 
or  to  say  the  multiplication  table.  Such  an  instance  has 
been  recorded  by  Volland.1  The  patient  was  completely 
speechless,  except  that  he  could  count  up  to  one  hundred 
and  say,  "  Once  one  is  one,"  etc.  A  much  more  interest- 
ing retention  is  that  sometimes  met  in  polyglots,  i.e.,  in 
patients  who  before  their  illness  could  speak  with  fluency 
other  languages  than  their  mother  tongue.  The  loss  of 
speech  in  such  an  individual  may  be  complete  for  one  or 
all  of  the  foreign  languages,  while  for  the  mother  tongue 
it  may  be  only  partial.  As  a  rule,  however,  in  these  cases 
the  ability  to  speak  is  entirely  lost  in  the  beginning  of  the 

1  Volland  :  "  Aphasie  apres  une  blessure  de  la  tete  ;  conservation  de  la 
faculte  de  compter. "  Milnch.  med.  Wochen.,  iSSG,  No.  4. 


Motor  Aphasia.  175 

disease,  but  after  a  time  the  patient  may  gradually  regain 
the  capacity  to  speak  his  mother  tongue,  but  not  the  foreign 
languages,  the  languages  that  he  acquired  at  a  later  period 
in  life  than  the  mother  tongue.  Such  cases  have  been 
reported  by  Charcot  and  by  others,  and  the  subject  has 
recently  been  studied  very  carefully  by  Pitres.1  The  ex- 
planation given  by  this  writer  is  one  that  must  meet  with 
universal  acceptance.  The  phenomenon  does  not  in  any 
way  posit  the  existence  of  separate  word-image  centres 
for  different  languages.  On  the  contrary,  it  is  explained 
by  the  fact  that  the  word  images  in  one's  mother  tongue 
are  more  indissolubly  imprinted  or  enregistered  in  the 
area  for  the  storage  of  word  images,  and  consequently  they 
are  the  least  readily  dislodged  or  destroyed  with  lesions  of 
this  area  that  are  not  of  sufficient  intensity  to  destroy  it 
completely. 

Inability  to  recall  substantives  or  verbs  is  the  condition 
to  which  the  name  amnesia  verbalis  is  given.  This  con- 
dition is  to  be  distinguished  from  that  to  which  the  term 
ataxia  verbalis  is  sometimes  applied  to  indicate  the  disa- 
bility of  producing  and  co-ordinating  the  movements  that 
subserve  articulation,  and  which  is  such  a  prominent  fea- 
ture in  subcortical  motor  aphasia  that  the  term  ataxic 
aphasia  has  been  applied  to  it.  Wyllie  deprecates  the 
fact  that  the  term  asynergia  verbalis,  suggested  originally 
by  Lordat  to  denote  the  disablement  of  speech  in  motor 
aphasia,  has  not  been  retained,  as  it  means  the  want  of 
power  of  working  together,  as  this  is  really  what  exists 
in  subcortical  motor  aphasia,  and  not  that  which  is  sug- 

1  Pitres  :    "  L'aphasie  chez   les  polyglottes."     Rev.    Me'd..   November, 


I  76  The  Faculty  of  Speech. 

gested  by  ataxia,  which  means  want  of  order.  But  I  can- 
not agree  with  the  distinguished  Scotchman  in  this,  for 
the  term  asynergia  verbalis,  although  extremely  pertinent, 
does  not  encompass  the  defect  entirely ;  there  is  ataxia  as 
well. 

According  to  the  conception  of  speech  promulgated  by 
Charcot,  the  amount  of  amnesia  verbalis  in  motor  aphasia 
should  depend  very  largely  on  the  category  to  which  the 
patient  belongs.  If  he  were  a  moteur,  that  is,  if  he  de- 
pended largely  on  the  evocation  of  articulatory  memories 
to  jut  thought  or  memories  into  consciousness,  then  de- 
struction of  the  cortical  area  in  which  are  stored  such 
memories  would  reduce  the  vocabulary  of  the  patient 
much  more  materially  than  if  he  were  an  auditif  or 
a  visncl.  If  the  patient  were  an  anditif  and  called  up 
words  and  names  habitually  by  a  revivication  of  audi- 
tory images,  articulate  verbal  amnesia  would  be,  compared 
with  the  previous  condition,  very  slight.  The  logic  of 
this  is  unassailable,  but  unhappily  for  the  advocates  of 
the  view  the  premises  are  false,  and  the  conclusions  are 
not  in  accord  with  clinical  experience.  Probably  no  one 
speaks  from  a  primary  evocation  of  the  images  of  articula- 
tion, and  the  loss  of  evocation  of  names  and  words  in  par- 
tial motor  aphasia  is  due  to  the  fact  that  there  is  always 
a  disability  in  the  arousal  of  auditory  images  spontaneously 
in  this  condition. 

A  patient  with  cortical  motor  aphasia  is  unable  to  express 
his  thoughts  in  writing.  His  capacity  to  write  is  propor- 
tionate to  the  amount  of  derangement  of  internal  lan- 
guage, and  it  bears  a  definite  relation  to  the  amount  of 
latent  or  actual  visual  amnesia  of  words  which  every  patient 


Motor  Aphasia.  \-j 

with  cortical  motor  aphasia  has.  In  most  cases  the  ca- 
pacity to  write  is  limited  to  writing  the  name  and  a  few 
other  words,  such  as  the  age,  the  address,  and  the  name 
of  the  wife  or  the  parents,  that  have  been  done  so  habit- 
ually, automatically,  and  frequently  that  they  form  a  part 
of  the  patient's  habitual  acts,  and  are  done  almost  re- 
flexly.  Motor  aphasia  is  almost  invariably  associated,  at 
least  in  the  beginning,  with  right-side  hemiplegia  due  to 
extension  of  the  lesion  on  which  the  aphasia  is  dependent 
to  the  psycho-motor  zone,  and  this  hemiplegia  prevents 
the  patient  from  writing  with  the  right  hand.  Although 
most  educated  people  can  write  with  the  left  hand,  of 
course  more  clumsily,  less  gracefully,  and  with  greater 
effort,  than  with  the  right  hand,  they  can  accomplish  it ; 
and  if  for  any  reason  the  right  hand  becomes  disabled 
they  acquire  within  a  few  weeks  the  ability  to  write 
with  the  left  hand  with  ease  and  facility.  But  a  patient 
with  cortical  motor  aphasia  is  completely  agraphic,  never 
learns  to  write  with  his  left  hand,  no  matter  how  long 
he  may  live  after  the  aphasia  has  developed.  However, 
every  modality  of  writing  is  not  interfered  with ;  though 
writing  voluntarily  and  writing  from  dictation  are  prac- 
tically impossible,  yet  the  patient  is  able  to  write  from 
copy. 

This  preservation  of  the  capacity  to  write  from  copy  is 
entirely  in  harmony  with  the  explanation  that  suffices  for 
loss  of  the  ability  to  write  that  occurs  in  cortical  motor 
aphasia.  The  inability  of  patients  who  have  cortical 
motor  aphasia  to  write  spontaneously  and  from  dictation 
has  been  recognized  almost  from  the  beginning  of  the 
history  of  the  disease.  Trousseau  gave  much  space  to  a 


i  78  The  Faculty  of  Speech. 

discussion  of  it  in  his  lectures  on  aphasia  and  cited  many 
examples.  "  In  the  English  language  the  subject  was  fully 
discussed  by  Ogle  and  by  Gairdner,  particularly  by  the 
latter,  who  said  very  tersely  and  truthfully  that  the  motor 
aphasic  could  write  as  well  as  he  could  speak,  and  if 
unable  to  speak  he  was  also  unable  to  write.  There 
would  seem  to  be  entire  unanimity  of  opinion  of  the  oc- 
currence of  agraphia  with  cortical  motor  aphasia,  but  dif- 
ferent observers  put  widely  different  interpretation  on 
the  manner  of  its  occurrence.  Those  who  follow  the 
teachings  of  Charcot,  Exner,  Strieker, '  et  al.,  and  believe 
that  there  exists  a  special  centre  for  the  deposition  and 
storage  of  graphic  motor  images,  have  no  difficulty  in  ex- 
plaining it  by  saying  that  as  the  graphic  motor  centre  is 
adjacent  and  contiguous  to  the  centre  for  images  of  artic- 
ulation the  one  is  almost  always  affected  with  the  other. 
They  experience  a  very  serious  difficulty,  however,  when 
they  attempt  to  prove  the  existence  of  such  a  hypothetical 
centre,  as  well  as  when  they  seek  to  defend  the  autonomy 
of  any  one  centre  in  its  relation  to  finished  speech  or  to 
its  predominancy  in  furnishing  us  with  the  idea  of  a  word. 
Of  all  the  cases  of  aphasia  accompanied  by  autopsical 
details  on  record  there  is  not  one  that  can  be  used  suc- 
cessfully to  prove  the  separate  existence  of  a  graphic 
motor  centre.  As  pointed  out  in  another  chapter,  the 
existence  of  such  a  centre  is  opposed  to  the  conception 
of  speech  which  it  has  been  our  endeavor  to  set  forth 
in  these  pages. 

At  the  time  of  Trousseau  and  Gairdner,  when  sensory 

1  "  Zur   Lehre  von  der  Aphasie."     Wiener  med.  Blatt.,   1881,  vol.  iv., 
pp.  1,477,  1,509,  1,565- 


Motor  Aphasia.  179 

aphasia  was  as  yet  scarcely  differentiated,  the  explanation 
that  was  given  to  account  for  the  occurrence  of  agraphia 
was  more  nearly  in  accord  with  the  explanation  that  I 
believe  to  be  the  correct  one  than  that  which  many 
writers  give  to-day.  It  was  believed  that  in  these  cases 
the  lesion  extended  posteriorly  to  include  other  areas 
than  that  of  Broca's  convolution.  And  as  a  matter  of 
fact  that  is  just  what  sometimes  occurs.  In  every  case 
of  cortical  motor  aphasia  there  is  some  dyslexia,  which 
shows  that  the  visual  centre  in  which  are  stored  the  im- 
ages of  the  seen  word  (the  angular  gyrus)  is  functionally 
impaired.  This  impairment  may  be  slight,  and  if  the 
examination  to  reveal  it  is  made  some  time  after  the 
occurrence  of  the  aphasia  it  may  be  difficult  to  bring  it 
out.  It  has  been  shown  conclusively  by  Thomas  and 
Roiix1  and  by  others  that,  nevertheless,  it  exists,  though 
possibly  in  a  latent  form  in  every  case.  As  a  rule,  the 
verbal  blindness  is  slight  and  undergoes  restitution  even 
before  any  signs  of  improvement  are  manifest  in  the 
aphemia.  Agraphia  occurs,  then,  in  motor  aphasia  because 
the  idea  of  the  word  that  the  patient  wishes  to  write  vol- 
untarily or  from  dictation  is  lost.  In  writing  voluntarily 
it  is  necessary  in  every  instance  to  visualize,  that  is,  to 
call  up  the  visual  memory  or  image  of  the  letter  and  the 
word,  and  these  in  turn,  acting  upon  the  images  of  artic- 
ulation, evocate  them,  and  the  latter  guide  the  motor 
area  in  making  the  movements  that  transcribe  the  letters 
to  form  words.  In  educated  people  and  people  habituated 
to  writing,  it  may  be  necessary  to  arouse  the  articulatory 
images ;  a  short  circuit  may  be  established  between  the 

1  Hull.  Societe  Biologic,  February  22d,  1896. 


180  The  Faculty  of  Speech. 

visual  images  of  the  word  to  be  written  and  the  motor 
area  from  which  originate  the  movements  of  the  part  that 
grasps  the  pen,  but  it  is  extremely  improbable  that  this 
takes  place.  It  is  much  more  likely  that  the  sensory 
images  of  articulation  are  evoked  in  every  instance.  If 
one  watches  a  person  unaccustomed  to  writing,  or  a  be- 
ginner, indite  a  line  or  a  page,  he  will  find  almost  invari- 
ably that  either  the  lips  and  the  tongue  move  visibly  with 
the  tracing  of  each  letter  and  word,  or  the  words  are  dis- 
tinctly articulated.  Moreover,  if  one  asks  typewriters 
who  are  accustomed  to  take  dictation  directly  on  the  ma- 
chine how  they  transcribe  what  they  hear  said  to  them, 
it  is  probable  that  the  majority  will  say  that  they  do  so 
by  spelling  to  themselves  (but  still  most  audibly  to  them- 
selves) the  words  that  they  hear,  before  striking  the  cor- 
responding keys.  This  shows  that  there  is  with  the  visual 
image  of  the  word  a  corresponding  evocation  of  the  articu- 
latory  images.  When  the  area  in  which  are  stored  the 
articulatory  images  is  destroyed,  then  a  link  in  the  circuit 
by  whose  integrity  we  are  in  possession  of  the  proper  idea 
of  the  word,  and  so  capable  of  utilizing  it  in  any  form  of 
exteriorization,  is  gone,  and  the  result  is  failure  to  write 
it  and  failure  to  speak  it. 

This  loss  of  the  idea  of  the  word  is  one  of  the  distin- 
guishing features  of  every  form  of  cortical  aphasia  and 
the  absence  of  it  is  the  most  pathognomonic  accompani- 
ment of  subcortical  aphasia,  it  matters  not  what  the  degree 
of  the  aphasia  is.  In  subcortical  motor  aphasia  there  is 
no  dyslexia,  because  there  is  no  word  amnesia  of  any 
kind,  visual,  auditory,  or  aphemic,  and  the  patient  can 
write  with  the  left  hand,  or  with  the  right  if  not  para- 


Motor  Aphasia.  181 

lyzed,  with  as  much  ease  as  he  could  before  the  illness. 
This  ability  to  write  is  dependent  upon  the  possession  of 
the  conception  of  the  word,  and  particularly  upon  the 
ability  to  evocate  the  visual  image  of  the  word.  When 
such  evocation  is  possible,  voluntary  writing  and  copying 
from  dictation  are  done  without  hesitation  by  any  mobile 
part  of  the  body  accustomed  to  hold  the  pen.  The  right 
arm  being  almost  invariably  paralyzed  in  subcortical  motor 
aphasia,  this  prevents  writing  with  the  right  hand. 

Writing  from  copy  is  possible  in  motor  aphasia  and  in 
subcortical  motor  aphasia,  as  has  already  been  said.  Writ- 
ing from  copy  cannot  be  looked  upon  as  an  act  necessitat- 
ing realization  of  the  idea  or  concept  of  the  word,  and  it 
therefore  may  be  retained  when  such  idea  or  conception 
is  lost.  It  is  probable  that  copying  involves  no  intellec- 
tion except  that  entering  into  seeing  the  word  as  a  de- 
sign, and  then  the  copying  of  the  design,  conditioned  by 
a  psycho-motor  act.  The  notion  of  the  word  may  not 
enter  into  the  internal  language  at  all,  and  unless  the 
patient  reads  what  he  is  copying,  and  therefore  revivifies 
the  visual  memory  images  in  the  angular  gyrus,  he  may 
copy  writing  as  he  would  copy  a  figure  with  which  he  is 
not  familiar.  The  fact  that  these  patients  copy  print  in 
script  and  not  in  print,  however,  shows  that  they  do  not 
copy  mechanically  and  servilely,  and  this  is  explained  by 
the  fa:t  that  in  no  case  of  motor  aphasia  is  there  absolute 
inability  to  revivify  visual  memories ;  there  is  only  par- 
tial disability,  sufficient  being  left  to  orient  the  patient 
in  copying.  The  other  reason  is  that  man  is  habituated 
from  childhood  to  write  in  script  and  not  in  print,  and 
he  does  this  unconsciously  from  such  habituation.  Dys- 


1 82  The  Facility  of  Speech. 

lexia,  difficulty  in  reading  (reading  to  one's  self),  is  a 
common  accompaniment  of  cortical  motor  aphasia,  al- 
though it  may  be  wholly  recovered  from  and  often  exists 
only  in  a  latent  state.  In  some  instances  the  difficulty 
in  reading  is  so  pronounced  as  to  constitute  real  alexia. 
As  an  instance  of  well-marked  dyslexia,  even  in  a  case  of 
motor  aphasia  that  has  nearly  recovered,  I  may  cite  the 
following  instance,  which  may  at  the  same  time  serve  as 
an  example  of  typical  motor  aphasia : 

Philip  Masterson,  thirty-one  years  of  age,  a  right-handed, 
hard-working,  temperate  man,  the  father  of  three  healthy 
children,  was  stricken  suddenly  while  at  the  dinner  table 
with  a  complete  right-side  hemiplegia.  There  was  no 
coma,  or  at  least  it  was  not  sufficient  completely  to  ob- 
literate consciousness,  although  he  was  in  a  dazed  state 
for  several  days.  Loss  of  speech  existed  from  the  first. 
A  few  days  later  he  could  apparently  understand  what  was 
said  to  him,  and  made  some  efforts  to  answer,  yet  no  articu- 
late words  came  to  him ;  but  after  endeavoring  to  answer 
for  some  time  he  suddenly  blurted  out  the  word  "  Lizzie" 
(his  wife's  name),  and  thereafter  he  repeated  this  word 
almost  incessantly  when  he  was  spoken  to  and  when  he 
was  not,  and  when  he  wished  something  or  when  he  de- 
sired to  be  let  alone.  It  partook  of  the  nature  of  a  recur- 
ring utterance.  After  a  number  of  weeks  he  was  able  by 
pointing  to  indicate  what  he  desired  or  what  he  meant 
to  convey.  The  first  word  that  he  spoke  besides  the  word 
"  Lizzie"  was  after  he  had  received  a  visit  from  a  man 
with  whom  he  had  worked  for  many  years.  When  the  visit- 
or had  gone  he  very  quietly  articulated  the  word  "  Lynch," 
although  there  had  been  no  conversation  about  the  visitor 
after  he  had  left.  He  was  completely  agraphic,  unable 
to  form  the  most  crudely  printed  letter  with  the  left  hand. 


Motor  Aphasia.  183 

He  understood  when  spoken  to,  would  obey  quickly  and 
intelligently  simple  requests  when  they  were  of  such  a 
nature  that  a  partially  hemiplegic  man  could  obey,  and 
he  apparently  put  proper  interpretation  on  impressions 
received  through  the  optic  nerves.  When  any  one  spoke 
to  him  he  watched  the  movements  of  the  lips  very  atten- 
tively, and  sometimes  tried  to  articulate,  but  never  with 

J  » 

any  success.  Six  weeks  after  the  stroke  he  was  able  to 
articulate  the  words  "  Yes"  and  "  No,"  but  in  response 
to  the  invitation  that  he  should  tell  something  about  his 
illness,  he  was  quite  mute.  Gradually  he  began  to  use 
verbs  and  afterward  to  apply  names  to  persons  and  things. 
For  instance,  in  calling  the  children,  he  would  apply  the 
name  of  some  person  with  whom  he  had  worked,  or  of  some 
unknown  person,  or  even  the  name  of  some  object  in  the 
shop  where  he  had  worked.  Instead  of  saying,  "  Give  me 
my  stockings,"  he  said,  "  Give  me  those  kittens."  When 
he  asked  for  his  vest  he  said,  "  Hand  me  that  clock." 
One  day  he  wished  to  have  a  sponge,  and  endeavored  to 
convey  his  meaning  by  saying,  "  Where  are  the  chickens  ?" 
Immediately  after  making  such  errors,  which  were  often- 
times very  ludicrous,  he  would  recognize  the  impropriety, 
and  particularly  if  he  noticed  some  one  smiling,  and  would 
immediately  assume  a  facial  expression  as  if  searching  for 
the  right  word,  and  wind  up  by  saying,  "That's  damn 
funny."  If  he  were  asked  the  name  of  his  neighbor,  he 
would  at  once  and  without  the  slightest  hesitation  say, 
"  Robinson,"  but  would  recognize  his  error,  and  on  being 
asked  if  it  were  not  O'Connor  he  would  say,  "  Of  course 
it  is;  I  guess  I  ought  to  know."  At  this  time  he  ex- 
hibited well-marked  paraphasia.  If  the  sentence  con 
tained  no  proper  names,  he  would  use  the  requisite  ; 
proper  words  to  convey  his  idea,  but  they  did  not  come 
from  his  mouth  with  the  right  sequence.  This  was  some- 


184  The  Fac^{,lty  of  Speech, 

what  more  marked  when  he  endeavored  to  repeat  sentences 
and  when  he  tried  to  read  aloud.  It  was  also  present 
when  he  essayed  to  speak  sentences  that  he  had  formerly 
learned  by  heart,  such  as  the  Lord's  Prayer,  or  simple 
verses  of  poetry. 

He  was  very  loath  to  try  to  write  with  the  left  hand, 
and  it  was  only  with  the  greatest  difficulty  that  he  could 
be  induced  to  write  his  name  and  address,  but  after 
some  persuasion,  fortified  by  assurance,  he  did  so.  He 
was  able  to  copy,  and  copied  script  in  script,  and  print  in 
print,  but  he  was  quite  unable  to  write  anything  from 
dictation. 

On  being  given  a  number  of  detached  letters,  and  re- 
quested to  make  words  out  of  them,  and  then  a  sentence 
informing  me  when  he  had  last  been  to  the  hospital, 
he  framed  with  great  difficulty  the  words,  "  Last  Thurs- 
day." 

On  testing  him  for  powers  of  association  and  applying 
proper  names  to  certain  things  and  objects,  I  said  to  him, 
"  If  on  your  way  home,  you  see  great  black  clouds  coming 
up  in  the  sky,  and  it  begins  to  get  dark,  what  do  you  think 
is  going  to  happen?"  He  answered  very  promptly,  "A 
storm."  A  number  of  other  questions  of  similar  import 
were  answered  correctly.  One  of  his  answers  is  so  thor- 
oughly in  accord  with  the  teachings  that  one's  thoughts 
are  largely  reactionary  to  his  environment  that  it  deserves 
to  be  quoted.  I  said  to  him :  "  Suppose  you  were  on 
your  way  here,  Sunday  morning,  about  ten  o'clock ;  you 
hear  the  bells  ringing,  and  see  a  great  number  of  people 
going  into  a  large  stone  or  brick  building,  some  going  in 
singly,  others  in  couples,  some  in  groups;  what  would 
you  call  the  place  where  they  were  going?"  He  hesitated 
a  moment  and  then  said :  "  A  saloon,  I  suppose,"  and  the 
absurdity  of  it  was  not  apparent  to  him. 


Motor  Apkasia.  185 

The  following  is  a  stenographic  report  of  an  interview 
with  him  :  . 

Patient  (reading  from  newspaper).  —  Lead  pipe  his 
mande  hen  of  powerful  presses.  This  medi  in  operation 
before  he  invented  the  lead  pipe  places — press — the  lead 
pipe — no — they  was  about  every — s-sway — lead  was  cuts 
in  pieces  of  the  length  of  foot  or  two,  which  were  the 
roller — which  want,  then  rolled  between  grow  and  rollers 
into  lengths  of  to — of  about  ten  feets.  Length  being  the 
sahder,  the  solder,  the  solder  together  make  a  marse,  and 
some  longer  by  another  meadows,  meadow — ma-madow — 
shaped  lead  was  cut  off,  the  lengths  rolled  up,  an  so — and 
sa — and  sader — (cannot  say  that  now) — and  another  sader 
lead  pipe  was  drawn  in  thump  in  something  the  same  man- 
ner that  wire  was  drawn — ma-a — now  wait- — that  the  metis 
required.  (Lost  place  entirely;  cannot  go  on.)  The  lead 
pipe  presses  in  on  the  new.  No,  it  is  not  there.  The 
lead  pipe  press  is  not  new. 

Q.   Do  you  remember  what  you  have  been  reading? 

A.   Yes,  sir. 

Q.  You  do  remember  what  you  have  been  reading? 
Now  tejl  me  slowly  what  you  have  been  reading. 

A.  Oh,  about  the  lead  pipe  and  how  long  them  are  cut- 
ting it,  and  how  big  it  was  getting.  I  don't  know  of  any 
more. 

O.  Can't  you  remember  anything  else? 

A.    No,  not  as  I  know  of,  unless—    -  (hesitates). 

Q.   How  is  lead  pipe  made  ? 

A.   It  is  dumped  into  the  boiler,  isn't  it? 

Q.  Is  not  lead  pipe  made  by  means  of  powerful  presses  ? 

A.   Yes,  I  guess  they  are. 

O.  Before  the  presses  were  invented  how  was  lead  pipe 
made? 

A.   Oh,  I  don't  know  how  that  would  be. 


1 86  The  Faculty  of  Speech. 

Q    Why  don't  you  know  ? 

A.   I  don't  know;   but  I  don't  remember. 

Q.  Have  you  not  just  read  here  how  it  was  made  before 
the  presses  were  invented  ? 

A.  Yes,  in  that  paper?     Yes. 

Q.  Then  why  don't  you  tell  me  ? 

A.  I  don't  know. 

Q.   Did  you  understand  what  you  read  here  ? 

A.  No,  not  at  all. 

Q.  Why  did  you  not  understand  it? 

A.   I  don't  know. 

Q.  Before  you  were  sick  you  could  read  English  and 
understand  it,  could  you  not  ? 

A.  Why,  of  course;  I  wouldn't  look  for  anything.  I 
would  look  around  the  front  of  the  paper,  of  course,  and 
would  not  read  it  all. 

Q.  The  manufacture  of  lead  pipe  ought  to  interest 
you. 

A.  No,  sir ;  it  did  not  arrest  us — no,  we  did  not  make 
anything  out  of  it. 

Q.  But  you  are  interested  in  learning  how  such  a 
common  thing  as  lead  pipe  was  made  ? 

A.  No,  sir;  we  were  not  exactly  that;  we  were  but 
lead,  but  copper,  and  rocks. 

Q.  Do  you  see  the  words  when  you  attempt  to  read  ? 

A.   Yes,  sir. 

Q.  You  can  see  the  words,  following  on  one  after 
another  ? 

A.  No,  sir ;  I  sometimes  skip  over  a  line. 

Q.   Why  is  that  ? 

A.   I  don't  know. 

Q.  Even  when  you  read  a  verse,  do  you  understand 
what  you  have  read  ? 

A.    No. 


Motor  Aphasia.  187 

This  alexia  which  is  now  so  manifest  in  attempting  to 
read  is  probably  explained  by  the  fact  that  the  patient 
always  in  reading  evocated  the  articulatory  word  images. 
That  is,  the  impressions  received  through  the  visual 
images  were  transformed  into  articulatory  word  images 
before  they  were  carried  into  the  consciousness,  and  now, 
when  the  articulatory  word  images  are  partly  destroyed, 
visual  impressions,  although  properly  received,  do  not 
fully  enter  into  consciousness. 

Q.  Now,  I  want  you  to  repeat  after  me,  the  Pilgrim 
Fathers  landed  on  Plymouth  Rock  on  the  22d  of  De- 
cember. 

A.  The  plim — on  the  plim — the  plim — no,  the  plimbic 
rock. 

Q.    Repetition  of  sentence. 

A.  The  pil — the  pirn — the  rock.  The— can't  get  that 
out.  The  pirn (mutters).  , 

Q.  Now  we  will  try  another  sentence.  The  Declara- 
tion of  Independence  was  framed  by  Benjamin  Franklin. 

A.  The  bee — the  bee — the  bet  of  independence- 
no (hesitates). 

Q.  Now  I  am  going  to  ask  you  to  repeat  something 
very  much  easier.  Before  the  foreigner  can  become  an 
American  citizen  he  must  live  here  five  years. 

A.  Before  a  for'ner  who  had  lived  here— had— (mutters) 
had  to  go  back.  Is  that  it? 

Q.  (Repeating  the  question.)  You  know  that  is  the 
fact,  do  you  not  ? 

A.   Yes,  sir.     (Tries  to  repeat.)     Before  a  commoner, 
comner,    before    a    commoner    who    had    lived    here- 
couldn't  go  no  further. 

O.  Now,  I  shall  give  you  another  question.  The  Papal 
Dekgate  is  the  head  of  the  Catholic  Church  in  America. 


1 88  The  Faculty  of  Speech. 

A.  The  papal  dedicate  was — a — was — the — was — the 
papal — the  pap — cake — oh,  I  couldn't. 

Q.  Shall  I  repeat  it  for  you  ?  (To  wife.)  You  repeat 
it.  (She  cannot  remember  it  all,  whereupon  the  patient 
says  very  quickly :  He  is  a  head  of  the  U.  S.  of  America.) 

Q.   Repetition  of  sentence. 

A.  The  Papal  Delicate  is  the  head  of  the  United  States 
of  America. 

O.  Now  I  am  going  to  give  you  a  very  easy  one.  To 
go  to  the  theatre  is  a  pleasure. 

A.  To  go  to  the  theatre  is  a  pleasure. 

Q.  To  go  to  the  theatre  after  a  hard  day's  work  is  a 
restful  pleasure. 

A.  To  go  to  the  theatre  is  a  hard  day's  work — I  don't 
know  more — you  run  away  too  quick. 

O.    (Repeats.) 

A.  To  go  to  the  theatre  is  a  hard  day's  work  is  after  a 
rest  of  pleasure. 

Q.   Does  that  seem  reasonable? 

A.   Well,  I  don't  know  what  word  got  out  that  time. 

Q.   You  are  not  foolish,  are  you? 

A.   (Quickly.)      No,  not  a  bit,  as  I  know  of. 

O.  Now  I  will  take  one  more  sentence.  In  the  spring- 
time sparrows  chirp. 

A.  In  the  springtime  the — schu — eh-h-h — float — I  think 
— ah — no. 

Q.  Now,  Mr.  Masterson,  I  want  you  to  tell  me  slowly 
and  distinctly  how  this  sickness  of  yours  came  on. 

A.   I  don't  know  how  it  came  on. 

Q.   Describe  it. 

A.  Only  remember  coming  up  the  stairs ;  went  to  the 
hydrant,  and  came  over  and  laid  on  a  chair — chucked  on 
a  chair — that's  all  I  know. 

Q.  That  is  all  you  know  of  your  sickness  ? 


Motor  Aphasia.  189 

A.  That  is  all  I  know — that  time — well,  I  can't  move 
my  arm, 

Q.   Well,  tell  me  why  you  got  put  on  a  chair. 

A.   I  don't  know. 

Q.  What  happened? 

A.   I  could  not  eat  any  more. 

Q.  Now  answer  me  this  one  question.  Tell  me  what 
has  happened  to  you  since  the  time  when  you  were  first 
taken  sick. 

A.  Eh-a— I  couldn't  tell  you  that.  I  don't  know  what 
to  ask — em — is  going  around — I  can't  tell  him. 

Q.    Why  can't  you  tell  ? 

A.  Well,  I  can't  very  well.  I  do  not  remember  it  so 
well.  I  remember  the  day  I  got  sick,  that  is  all. 

Q.  Well,  tell  me  everything  that  happened  that  day. 

A.  Well,  I  worked  pretty  hard  that  morning — coming 
down  stairs — sometimes  jumped  down.  Then  went  home, 
of  course  and  had  that — that — e-e-a-e  (drawling).  Did 
not  eat  dinner  at  all.  I  fell  out  of  my  hand,  and  I  went 
over  to  the  hydrant. 

Q.    What  is  the  next  thing  that  you  remember? 

A.  That  is  all  now,  I  think. 

Q.   Can  you  remember  anything  else  ? 

A.  Well,  I  was  on  the  sofa,  and  I  was  lying  there,  and 
I  could  speak  to  them.  Ever  since  I  have  been  just  as 
good  as  ever.  I  ain't  done  any  more. 

Q.   Is  that  all  you  can  tell  ? 

A.   Yes;  I  don't  know. 

Q.  What  occurred  on  the  4th  of  March  in  this  country  ? 

A.  The  President  and  Vice- President  went  in.  They 
took  the  grand  opera  house. 

Q.   What  do  you  mean  by  that  ? 

A.   Why,  the  name  of  the  washing-house. 

Q.  You  mean  they  entered  the  White  House? 


i  go  The  Faculty  of  Speech. 

A.   Yes,  sir. 

Q.   What  else  occurred  in  the  White  House  ? 

A.  A  ball — was  there— all  big  women — high-toned 
women. 

Q.  Yes ;  but  who  went  out  ? 

A.   Cleveland. 

Q.   Where  did  he  go  ? 

A.   Oh,  I  don't  know  where  he  went. 

Q.   Did  you  not  hear  ?          • 

A.  No. 

To  test  his  memory  and  associative  faculties  a  few 
questions  such  as  the  following  were  asked : 

Q.  Name  me  all  the  four-footed  animals  you  can 
think  of. 

A.  Why —  (hesitates)  do  you  want  the  lion  ?  Buffalo 
— eh — the  lion —  (mutters)  did  I  say  buffalo  already  ? 

Q.   Name  all  the  two-legged  animals  that  you  can. 

A.  Bird,  chicken,  and  what  is  it  ?  (mutters)  I  think — 
of  'em  (hesitates,  mutters). 

Q.   Now  name  all  the  different  birds  that  you  can. 

A.  Chicken,  eagle — the-e — stuck  now. 

Q.   Have  you  been  in  the  country  ? 

A.  Yes. 

Q.  Now,  sitting  here,  if  you  should  suddenly  hear  some 
music,  hear  a  tune — the  tune,  "  On  the  Bowery" — where, 
in  all  probability,  would  it  come  from  ? 

A.  Why,  I  don't  know.  Somebody  had  an  accordeon, 
somebody  had  a  fiddle. 

Q.  Does  it  not  occur  to  you  that  it  might  be  a  hand- 
organ  in  the  street,  or  it  might  be  a  piano  upstairs  ? 

A.  Yes,  sir,  come  to  think  of  it. 

Q.   Can  you  whistle? 

A.   No,  sir. 

Q.   Why  not  ? 


Motor  Apkasia.  191 

A.  Can't  whistle  ever  since. 

Q.   You  know  tunes,  don't  you? 

A.  Well,  I  have  not  much  of  a  fancy  for  music. 

Q.  Tell  me  what  tune  this  is  as  I  whistle  it.  (Whistles 
"  Home,  Sweet  Home.") 

A.   Home,  sweet  mother. 

Q.   (Whistles  another  tune.) 

A.   Don't  know  that  tune. 

Q.    (Whistles  "  On  the  Bowery.") 

A.  Yes,  I  know  it,  but  I  can't  say  it.  It  can't  come 
into  my  head. 

Q.   It  is  "  On  the  Bowery,"   is  it  not? 

A.    Yes,  sir. 

O.   (Whistles  "Yankee  Doodle.")     What  is  that? 

A.  I  don't  know  what  the  deuce  it  is.  I  don't  know 
that  one. 

The  essential  features  of  this  case  are  the  total  loss  of 
articulate  speech  for  a  number  of  weeks  following  the 
attack  of  apoplexy,  then  the  gradual  possession  of  a  few 
words  to  signify  assent  and  negation,  and  later  the  names 
of  his  wife  and  of  one  or  two  of  the  men  with  whom  he 
had  long  worked  and  lived.  After  a  number  of  months 
his  vocabulary  began  to  increase  gradually,  particularly  in 
words  that  signified  action  or  quality.  In  the  use  of  these 
words  there  were  well-marked  paraphasia  and  amnesia  ver- 
balis  of  the  articulatory  memory  of  the  word.  In  addition 
to  this  the  patient  had  agraphia  and  dyslexia,  although 
there  was  no  sensory  aphasia,  word  blindness  or  word 
deafness,  optic  aphasia,  or  hemianopsia. 

The  most  interesting  feature  of  his  present  state  is  the 
agraphia  and  the  dyslexia.  He  has  been  tested  a  number 
of  times  with  the  block  alphabet,  and  although  he  can 


192  The  Faculty  of  Speech. 

frame  simple  words  it  requires  a  very  long  time,  and  he 
stops  after  he  has  made  a  few  simple  words,  some  of  which 
are  misspelled,  and  he  insists  that  he  is  not  able  to  go  on. 
The  dyslexia  is  strikingly  shown  by  the  transcript  of  an 
attempt  to  read  a  newspaper  paragraph  telling  how  lead 
pipe  is  made,  a  subject  in  which  he  should  be  interested, 
as  he  handles  that  article  in  his  occupation.  I  have  al- 
ready spoken  of  disturbances  of  reading  and  of  writing  in 
cortical  motor  aphasia  and  have  explained  how  they  de- 
pend upon  the  disablement  of  internal  language  which 
accompanies  every  case  of  cortical  aphasia. 

Subcortical  Motor  ApJiasia. 

The  term  subcortical  motor  aphasia  is  used  to  indicate 
a  partial  or  complete  inability  to  externalize  speech  which 
has  been  properly  formed  in  the  speech  centres  constitut- 
ing the  zone  of  language.  The  lesion  is  one  that  causes 
a  break  in  those  speech-carrying  neurons  extending  from 
the  portion  of  the  Rolandic  cortex  to  which  is  allocated 
the  representation  of  the  different  parts  of  the  peripheral 
speech  mechanism  to  the  cells  constituting  the  peripheral 
neurons  of  the  same  mechanism.  Some  recent  writers, 
such  as  Ziehen,1  use  the  term  fascicular  anarthria  to  indi- 
cate the  same  condition.  The  earliest  important  contri- 
bution to  the  differentiation  of  subcortical  motor  aphasia 
was  made  by  Pitres,2  in  1877,  when  he  essayed  to  study 
the  symptomatology  of  lesions  of  the  centrum  ovale.  At 

'  Ziehen  :  Article  "  Aphasie."  Eulenburg's  "  Real  Encyclopedic, "  sup- 
plementary volume. 

2  Pitres  :  "  Recherches  sur  les  lesions  du  centre  ovale."  These  de 
Paris,  1877. 


Motor  Aphasia.  193 

that  time  Pitres  believed  that  there  was  no  difference 
clinically  between  aphasia  caused  by  lesion  of  Broca's  area 
and  that  caused  by  lesion  of  subjacent  white  fibres.  This 
was  a  legitimate  supposition,  in  full  accord  with  the  an- 
atomical and  physiological  teachings  of  the  times.  It 
was  at  that  time  supposed  that  Broca's  convolution  was 
the  unique  area  of  language  and  that  in  functioning  it 
transmitted  its  influence  by  means  of  bundles  of  white 
fibres,  the  inferior  pediculo-frontal  fascicle,  to  the  bulbo- 
medullary  centres  which  conditioned  the  execution  of 
speech.  Therefore  it  was  logical  to  suppose  that  inter- 
ruption of  the  fibres  constituting  this  pathway  would 
cause  the  clinical  equivalent  of  destruction  of  the  cor- 
tical area  of  which  it  was  said  to  be  the  projection.  The 
conclusion  would  have  been  unassailable  if  the  premises 
were  correct.  At  the  present  day  no  one  believes  Broca's 
area  to  be  the  unique  organ  of  aphasia,  and  modern  inves- 
tigation has  shown  conclusively  that,  even  if  it  were,  it 
sends  no  fibres  into  the  great  motor  projection  system 
that  passes  through  the  internal  capsule  on  the  way  to 
the  motor  cranial-nerve  nuclei  and  the  pyramidal  tracts. 
The  completest  destruction  of  Broca's  area  entails  no 
paralysis  of  the  lips,  the  tongue,  the  palate,  or  the  larynx. 
Anatomists  have  shown  that  the  speech  centres  in  the 
zone  of  language  are  association  centres,  intimately  inter- 
connected by  commissural  fibres  and  devoid  of  projection 
fibres.  The  lower  end  of  the  ascending  frontal  convo- 
lution immediately  adjacent  to  the  portion  of  the  area  of 
language  in  which  are  stored  articulatory  kinaesthetic  im- 
ages (Broca's  area)  is  the  executive  area  of  the  zone  of 
language.  When  this  executive  area  is  destroyed,  or  when 
'3 


194  The  Faculty  of  Speeck. 

all  the  projection  fibres  going  out  from  it  to  the  motor 
cells  constituting  the  beginning  of  the  peripheral  neurons 
which  go  to  the  speech  apparatus  are  destroyed,  there  may 
be  inability  to  articulate,  which  is  just  as  complete  and 
total  as  if  Broca's  area  was  destroyed,  but  the  zone  of  lan- 
guage is  intact  and  therefore  internal  speech  is  unim- 
paired. 

The  symptoms  of  subcortical  motor  aphasia  are  practi- 
cally the  same  as  those  attending  destruction  of  Broca's 
area,  with  two  striking  and  all-important  exceptions.  The 
first  of  these  is  that  the  patient  retains  the  capacity  to 
write,  which  it  will  be  remembered  is  lost  in  cortical 
motor  aphasia  proportionately  to  the  completeness  of  the 
aphasia,  and,  secondly,  the  patient  responds  to  the  Proust- 
Lichtheim  test;  that  is,  he  can  indicate  by  movement 
in  some  form,  by  squeezing  the  physician's  hand,  by  mak- 
ing expiratory  efforts,  by  winking,  etc.,  the  number  of 
syllables  that  constitute  a  given  word  or  the  number  of 
letters.  In  other  words,  he  can  prove  to  the  satisfaction 
of  his  examiners  that  he  retains  the  ability  to  call  up 
spontaneously  the  .sound  of  the  word,  the  visual  image 
of  the  word,  and  the  articulatory  memory  of  the  word. 

One  of  the  most  interesting  and  instructive  examples 
of  subcortical  motor  aphasia  in  general  literature,  and 
there  are  many  such,  is  that  of  the  illustrious  Samuel 
Johnson.  He,  after  suffering  for  a  number  of  hours  with 
a  curious  sensation  in  the  head,  found  that  he  had  lost 
the  power  of  articulate  speech,  though  he  could  write 
with  customary  facility.  This  filled  him  with  a  porten- 
tous dread,  although  it  is  probable  that  his  concern  was 
in  nowise  comparable  to  that  of  Boswell,  who  foresaw  in 


Motor  Aphasia.  195 

this  catastrophe  the  perishment  of  all  that  life  held  dear 
to  him ;  the  transmission  to  paper  of  Johnson's  Solonic 
utterances.  Johnson,  desiring  to  convince  himself  that 
his  intelligence  was  not  impaired,  essayed  to  write  Latin 
verse,  which  he  did  with  customary  ease.  He  also  in- 
dited a  letter  in  the  same  language  to  his  physician.  This, 
in  addition  to  being  complimentary  to  the  intelligence  of 
the  latter  and  to  the  profession  of  his  day,  showed  clearly 
that  the  memory  of  the  word  in  all  of  its  forms,  audi- 
tory, visual,  and  articulate,  was  intact,  and  that  there 
was  no  disturbance  of  internal  language.  Even  the  oc- 
currences attending  the  final  attack  were  typical  of  sub- 
cortical  motor  aphasia.  After  consciousness,  which  had 
been  submerged  during  an  apoplectic  attack,  was  re- 
gained Johnson  essayed  to  speak  in  the  English  language. 
Finding  that  he  could  not  do  so,  he  tried  to  talk  Latin, 
but  found  this  impossible.  He  then  uttered  a  few  words 
in  Greek  with  greatest  difficulty.  Notwithstanding  this 
difficulty  in  communicating  his  thoughts  by  articulate 
speech  in  any  of  the  languages  that  had  been  familiar  to 
him,  he  wrote  a  Latin  hymn  addressed  to  the  Creator,  the 
prayer  of  which  was  that  so  long  as  the  Almighty  should 
be  pleased,  graciously,  to  permit  him  to  live,  he  should 
be  allowed  to  have  the  enjoyment  of  his  understanding, 
that  his  intellectual  and  bodily  powers  should  expire  to- 
gether. This  shows  satisfactorily  that,  although  he  could 
not  manifest  thoughts  in  external  speech,  internal  speech 
was  intact  and  that  it  could  be  externalized  by  writing. 

In  discussing  the  clinical  manifestations  of  subcortical 
motor  aphasia,  I  shall  record  a  few  cases,  beginning  with 
the  simplest,  in  which  the  phenomena  are  closely  restricted 


The  Faculty  of  Speech. 

to  inability  to  execute  the  movements  of  articulation.  I 
shall  then  take  up  the  more  complex  forms  of  subcortical 
motor  aphasia.  The  following  case,  which  occurred  in 
the  practice  of  Dr.  J.  C.  Kendall,  and  to  whom  I  am 
indebted  for  the  notes,  may  be  cited  as  one  of  the  most 
restricted  examples  of  subcortical  motor  aphasia  that  I 
have  seen.  The  history  of  the  case  is  much  abridged. 

A  seventeen-year-old  schoolboy  felt  quite  well  on  the 
1 9th  of  May.  On  the  following  day  he  noticed  that  his 
right  arm  was  clumsy  and  awkward,  and  while  in  school 
he  was  not  able  to  use  the  pencil  dexterously.  On  the 
following  day  there  was  much  impairment  of  strength  of 
the  right  side  of  the  body,  and  he  dressed  himself  with  a 
great  deal  of  difficulty  and  got  down  stairs.  On  attempt- 
ing to  cross  the  floor,  he  fell.  Examination  of  the  patient 
soon  afterward  showed  a  right-side  hemiplegia,  the  arm 
being  most  affected,  the  face  less  so,  and  the  leg  still 
possessed  of  sufficient  motility  to  be  flexed  and  extended. 
There  was  slight  twitching  of  the  right  angle  of  the 
mouth.  The  tongue  protruded  naturally,  and  the  pupils 
were  of  equal  size  and  responsive.  At  this  time  it  was 
distinctly  noticed  that  there  was  no  impairment  of  speech. 
On  the  following  day  the  right  leg  became  paralyzed,  and 
his  vocabulary  was  limited  to  the  use  of  the  words  "  Yes" 
and  "  No."  He  understood  everything  that  was  said  to 
him,  and  was  keenly  appreciative  of  his  surroundings  and 
environment.  During  his  illness  he  diverted  himself  with 
pictures,  and  often  read,  which  he  seemed  able  to  do  un- 
derstandingly.  Impressions  coming  through  the  visual 
apparatus  and  auditory  apparatus  were  heard  and  inter- 
preted. On  the  following  day  he  could  not  articulate  a 
word.  He  understood  words  readily ;  he  could  indicate 
the  number  of  syllables  in  a  word  by  pressing  the  physi- 


Motor  Aphasia.  197 

clan's  hand  the  same  number  of  times  as  there  were  syl- 
lables in  a  spoken  or  written  word.  The  hemiplegia  re- 
mained the  same.  Five  days  later  he  was  able  to  make 
slight  movements  with  the  toe  of  his  right  foot.  The 
next  day,  that  is,  one  week  after  speech  disturbances  first 
manifested  themselves,  he  articulated  the  word  "  Paper," 
pointing  to  a  newspaper  that  was  lying  on  a  distant  table, 
and  which  he  wished  to  get.  The  next  day  he  said 
"  Yes,"  in  response  to  a  question.  From  this  time  on 
he  regained  the  ability  to  speak  and  at  the  end  of  a  week 
he  was  able  to  answer  and  talk  voluntarily  in  a  stammer- 
ing, hesitating  manner.  He  never  misplaced  words,  nor 
did  he  use  words  incorrectly.  The  hemiplegia  disap- 
peared rapidly,  and  a  month  from  the  time  when  he  was 
stricken  he  could  walk  and  run,  and  use  his  right  upper 
extremity,  even  to  perform  such  complex  movements  as 
writing,  although  this  was  very  awkwardly  done.  Six 
months  after  the  attack  there  were  no  trace  of  hemiplegia, 
except  a  slight  exaggeration  of  the  knee  jerks  on  the  right 
side,  and  no  trace  of  speech  disturbance. 

The  clinical  history  of  this  case,  particularly  its  mode 
of  development,  course,  and  termination,  indicates  that  the 
pathological  lesion  was  of  the  nature  of  a  thrombosis, 
while  a  study  of  the  speech  defects  shows  that  the  pa- 
tient was  in  possession  of  the  faculty  of  language  in  all 
its  components,  including  articulatory  kinaesthetic  images, 
but  that  he  was  not  able  to  give  expression  to  his  properly 
formed  thoughts  and  words  on  account  of  some  interrup- 
tion of  continuity  between  the  area  where  such  articula- 
tory kinaesthetic  images  are  stored  and  the  peripheral 
executive  apparatus  of  speech.  In  short,  the  case  is  one 
of  subcortical  motor  aphasia,  or  pure  motor  aphasia  of 
Dejerine.  Although  this  is  fully  apparent  from  a  study 


198  The  Faculty  of  Speech. 

of  the  speech  defect  alone,  a  consideration  of  the  manner 
of  his  recovery  makes  the  truth  of  this  much  more  ap- 
parent. If  the  cortical  area  in  which  are  stored  the  sen- 
sory articulatory  images  had  been  destroyed,  the  mode  of 
recovery  would  have  been  quite  different.  In  such  case 
learning  to  talk  would  have  been  a  slow  and  tedious 
process. 

It  may  possibly  be  urged  that  the  thrombotic  lesion 
interfered  with  the  vascular  supply  of  Broca's  convolu- 
tion, and  so  temporarily — that  is,  during  the  period  when 
the  vessel  was  thrombosed — prevented  this  convolution 
from  functioning ;  but  the  fact  that  the  patient  recognized 
the  number  of  syllables  in  a  word,  thus  showing  the  pos- 
session of  articulatory  images,  is  opposed  to  this  view. 
The  case,  then,  is  one  of  strictly  motor  aphasia  in  the 
same  sense  as  the  paralysis  of  the  right  arm  was  motor, 
and  it  is  explained  in  exactly  the  same  way.  The  motor 
projection  fibres  that  convey  the  speech  impulses  were 
temporarily  interrupted  just  as  the  projection  fibres  that 
convey  simple  motor  impulses  were  interrupted. 

Writers  are  by  no  means  in  accord  as  to  the  location  of 
the  lesion  that  causes  subcortical  motor  aphasia.  Pitres, 
in  a  very  recent  contribution  to  the  subject,  contends  that 
destructive  lesions  of  the  white  substance  adjacent  to  the 
foot  of  the  third  frontal  convolution  on  the  left  side 
cause  aphasia  which  cannot  be  differentiated  from  true 
cortical  aphasia,  and  that  the  symptoms  of  subcortical 
aphasia  are  dependent  upon  lesions  situated  in  the  central 
part  of  the  cerebral  hemispheres  and  contiguous  to  the 
internal  capsule.  Very  few  writers  are  willing  to  concede 
this.  It  is  undoubtedly  true  that  it  is  oftentimes  ex- 


Motor  Aphasia.  199 

tremely  difficult  to  differentiate  between  aphasia  due  to 
lesion  of  Broca's  area  and  subcortical  lesions  subjacent 
to  it ;  but  it  is  my  belief  that  in  every  instance  it  can  be 
differentiated  if  the  patient  be  studied  with  sufficient  care 
and  persistence,  particularly  with  reference  to  his  internal 
language,  the  ability  to  read,  to  write  with  the  detached 
alphabet,  etc.,  not  to  speak  of  the  Proust- Lichtheim  test 
and  the  information  to  be  derived  from  objective  study  of 
the  patient.  It  is  not  denied  that  lesion  of  the  projection 
tracts  at  the  level  of  the  capsule  sometimes  produces  a 
symptom  complex  very  similar  to  that  attending  lesion  of 
the  white  substance  immediately  subjacent  to  the  lower 
end  of  the  area  of  Broca  and  the  ascending  frontal  convo- 
lution. Cases  in  proof  of  this  have  been  recorded  by 
Banti,  by  Dejerine,  and  other  most  trustworthy  writers 
on  this  subject. 

The  case  of  Banti  is  a  very  typical  one.  A  man,  sixty- 
two  years  old,  who  had  never  learned  to  read,  was  stricken 
with  apoplexy,  followed  by  right-side  hemiplegia  and  in- 
ability to  speak.  He  understood  everything  that  was  said 
to  him,  and  he  endeavored  to  respond,  but  the  only  result  of 
such  efforts  was  a  sound  comparable  to  "  tititititi."  When 
words  of  one  syllable  or  individual  letters  were  spoken 
before  him  and  he  was  requested  to  try  to  say  them,  he 
could  articulate  some  of  them  so  that  they  could  be  under- 
stood, if  he  did  it  very  slowly  and  with  great  deliberation. 
He  died  five  years  after  the  apoplectic  attack,  there  being 
in  the  mean  time  very  little  change  in  the  state  of  his  ex- 
pressive faculties.  On  autopsy,  there  was  found  an  apo- 
plectic cicatrix,  of  a  brownish-yellow  color,  at  the  level  of 
the  internal  capsule,  between  the  lenticular  nucleus  and 


2oo  The  Faculty  of  Speech. 

the  thalamus — that  is,  in  the  anterior  part  of  the  posterior 
segment  of  the  capsule. 

Another  case  related  by  Dejerine  is  even  more  instruc- 
tive, for  the  patient  was  a  man  of  some  education  and  the 
Proust- Lichtheim  test  was  applied.  The  patient,  sixty- 
seven  years  old,  had  right-side  hemiplegia  and  aphasia 
of  many  years'  standing.  There  was  absolute  impossibil- 
ity to  speak  aloud,  but  he  could  whisper  words  that  were 
intelligible.  He  was  able  also  to  indicate  very  well  the 
number  of  syllables  in  words  that  he  was  entirely  unable 
to  pronounce.  There  was  no  agraphia  or  paragraph i a. 
The  autopsy,  made  eleven  years  after  the  first  apoplectic 
stroke,  showed  three  small  foci  of  softening  situated  in 
the  anterior  of  the  hemisphere,  one  in  the  middle  of  the 
internal  capsule,  one  in  the  caudate  nucleus,  the  third  in 
the  fibres  of  the  white  substance  subjacent  to  the  foot  of 
the  third  frontal  convolution. 

The  recitation  of  one  case  or  of  a  hundred  cases  of  sub- 
cortical  motor  aphasia  in  which  the  autopsy  showed  the 
symptom  to  be  dependent  upon  a  lesion  of  the  projection 
tracts  at  the  level  of  the  capsule  in  nowise  militates  against 
the  statement  that  lesion  at  other  levels  higher  than  this, 
even  up  to  the  cortex  of  the  Rolandic  area,  from  which 
starts  the  projection  tract,  may  produce  the  symptom  com- 
plex of  subcortical  motor  aphasia,  and  therefore  I  venture 
to  think  that  Pitres  takes  an  entirely  unjustifiable  and  un- 
tenable position  in  saying  that  "  it  occurs  only  when  the 
lesions  are  situated  at  the  level  of  the  internal  capsule  or 
at  the  origin  of  the  capsular  irradiation,"  unless  the  capsular 
irradiation  begins  at  the  motor  cortex.  It  would  seem  to 
me  that  if  the  following  case,  recorded  by  Dejerine,  were 


Motor  ApJiasia.  201 

the  only  one  at  our  disposal  it  would  disprove  Pitres'  con- 
tention. The  patient  had  incomplete  hemiplegia  of  the 
right  side;  no  sign  of  verbal  blindness  or  verbal  deafness. 
The  patient  understood  everything  that  was  said  to  him. 
He  was  unable  to  pronounce  a  single  word,  to  read  in  a 
loud  voice,  or  to  repeat  aloud.  The  motor  word  images 
were  meanwhile  intact,  because  when  he  essayed  to  speak 
he  made  as  many  efforts  of  expiration  (Dejerine's  applica- 
tion of  the  Proust- Lichtheim  suggestion)  as  there  were 
syllables  in  the  word.  He  wrote  easily  with  the  left 
hand.  At  the  autopsy,  an  incision,  passing  horizontally 
to  the  foot  of  the  third  frontal  convolution  and  not  im- 
plicating the  caudate  nucleus,  showed  an  oval  spot  of  soft- 
ening three  centimetres  long  and  two  wide  beneath  the 
foot  of  the  third  frontal,  reaching  into  the  subjacent  white 
substance  as  far  as  the  lower  extremity  of  the  ascend- 
ing frontal  and  parietal  convolutions.  I  believe,  more- 
over, that  in  many  instances  cases  of  subcortical  motor 
aphasia  due  to  lesion  at  the  level  of  the  capsule  can  be 
differentiated  from  those  due  to  lesion  closely  subjacent 
to  the  cortex,  and  from  a  consideration  of  the  objective 
symptoms  alone. 

Before  taking  up  an  analysis  of  these  differentiating  symp- 
toms, I  shall  cite  two  cases  of  subcortical  motor  aphasia, 
the  first  an  example  of  a  subcortical  lesion  situated  near  to 
the  cortex,  the  second  due  to  a  lesion  at  the  level  of  the  cap- 
sule. Opportunity  was  given  to  study  the  following  case 
through  the  courtesy  of  my  friend,  Dr.  Joseph  Fraenkel : 

M.  W ,  thirty-three  years  old,  married  ;  the  father  of 

healthy  children ;  a  native  of  Polish  Russia ;  by  occupa- 
tion a  tailor;  and  of  good  family  and  personal  history. 


202  The  Faculty  of  Speech. 

Four  years  ago  he  was  carrying  a  sewing-machine  in  the 
street,  and  fell,  on  account  of  weakness.  He  went  home, 
complained  of  severe  headache,  was  not  able  to  be  about, 
and  the  next  day  sent  for  a  physician,  who,  after  attend- 
ance upon  him  for  a  day  or  two,  diagnosticated  typhoid 
fever.  Five  days  after  he  had  taken  to  his  bed,  he  be- 
came unconscious,  and  so  remained  for  about  sixty  hours. 
When  he  regained  consciousness,  he  was  paralyzed  on  the 
right  side  and  unable  to  speak.  After  six  weeks  his  gen- 
eral condition  began  to  improve,  and  in  a  short  time  he 
was  able  to  be  taken  out  of  bed.  Paralysis  of  the  right 
side  of  the  body  persisted. 

Examination  shows  a  well-nourished,  intelligent-looking 
man,  of  good  disposition,  who  is  apparently  able  to  look 
after  himself.  He  goes  all  over  the  ward  and  out  of  doors 
in  a  wheel  chair,  which  he  manages  with  great  readiness. 
Aside  from  the  spastic  hemiplegia  of  the  right  side,  which, 
however,  does  not  involve  the  face,  and  the  speech  defects, 
his  physical  and  mental  conditions  are  very  satisfactory. 
He  has  been  examined  repeatedly,  and  the  results  of  these 
examinations  are  monotonously  uniform. 

What  is  your  name  ?  A.  (Shakes  his  head  and  smiles 
sadly.) 

How  old  are  you?  A.  (Holds  up  three  fingers  twice, 
then  puts  his  hand  to  his  lips ;  then  quickly  reaches  for 
the  pencil  with  which  I  am  writing;  takes  the  pencil 
and  writes  "  33.") 

Are  you  thirty-three  years  old?  A.  (Nods  affirma- 
tively and  nonchalantly.) 

Are  you  married  ?  (Affirmative  nod  of  the  head ;  then, 
when  he  notes  that  I  am  still  waiting,  he  writes  "  Yes." 
Then,  without  being  asked,  he  holds  up  in  succession  five 
fingers  and  four  fingers,  to  indicate  that  he  has  been 
married  nine  years.) 


7i/r  ^ 
Motor  .>,*^       '•  203 

-v^~     ^/  O 

Have  you  children  ?  A.  (Holds  up  one  finger.)  Is  it 
a  boy  or  a  girl?  A.  (Smiles  and  makes  a  nod  of  nega- 
tion.) 

I  want  you  to  tell  me  if  your  child  is  a  boy  or  a  girl  ? 
"  B'  B'  ba"  (that  is,  he  endeavors  to  say  "  boy,"  which  is 
the  correct  answer,  but  he  is  unable  to  articulate  it.) 

How  old  is  he?  (Holds  up  five  fingers  and  then  three 
fingers  to  indicate  that  he  is  eight  years  old.) 

What  is  your  wife's  name?  A.  (Reaches  for  pencil, 
and  writes  in  distinct  Hebrew  characters  the  word 
"  Rachel.") 

It  should  be  said  here  that  the  patient  is  fairly  well 
educated  in  the  use  of  his  own  language.  He  has 
learned  to  write  with  the  left  hand.  He  spends  his  time 
in  writing  letters  to  his  family  and  friends,  and  in  put- 
ting on  paper  his  memories,  thoughts,  and  hopes.  The 
Hebrew  language  readily  lends  itself  to  construction 
by  the  left  hand,  its  continuity  being  from  right  to  left, 
and  this  patient  writes  with  great  distinctness  and  ac- 
curacy. It  would  seem  on  testing  him  a  great  many 
times  that  he  writes  spontaneously  with  more  ease, 
accuracy,  and  correctness  than  from  dictation.  When,  how- 
ever, dictation  is  slow  and  he  is  not  hurried,  he  repro- 
duces most  commendably.  Many  of  his  written  produc- 
tions he  carries  with  him,  and  when  they  are  read  it  is 
seen  that  not  only  the  thoughts  but  the  diction  are  very 
creditable.  In  response  to  simple  questions  or  sugges- 
tions, such  as,  "  How  would  you  ask  the  nurse  to  get 
you  a  glass  of  water?"  he  fixes  the  nurse  in  his  gaze, 
nods  to  him  expressively,  points  first  to  a  glass,  then  in 
the  direction  of  the  hydrant,  and  then  to  himself.  After- 
ward he  makes  a  movement  of  carrying  the  glass  to  his 
lips.  When  asked  to  put  out  his  tongue,  to  close  the 
eyes,  to  squeeze  my  hand  the  same  number  of  times  as 


V 


204  J      &          of  Speech. 

there  are  syllables  in  the  word  "  Constantinople,"  he  does 
so  very  intelligently  and  correctly.  The  nurses  and  order- 
lies in  the  hospital  say  that  he  never  makes  use  of  articu- 
late words. 

The  sensory  side  of  his  speech  mechanism  is  apparently 
intact.  On  being  asked  if  he  understands  everything  that 
he  reads,  he  nods  his  head  in  the  affirmative,  and  writes 
"Yes."  On  being  asked  to  read  a  paragraph  from  a 
Hebrew  newspaper,  and  then  to  write  its  significance  or 
meaning  he  does  so  consistently,  but  uses  nearly  the  same 
words  that  he  has  read.  Numerous  attempts  were  made 
with  this  patient  to  determine  whether  or  not  internal 
speech  was  intact.  On  every  occasion  he  was  able  to  in- 
dicate the  number  of  syllables  in  a  spoken  word,  the  num- 
ber of  letters  in  a  word,  to  write  quickly  the  names  of 
objects.  In  response  to  the  question  if  he  hears  in  his 
ears  the  sounds  of  the  words  that  he  reads,  he  writes 
"Yes."  As  to  his  hearing  them  with  the  same  distinct- 
ness as  when  they  are  spoken,  he  answers  "  No,"  but  that 
he  hears  them  within  himself.  It  may  be  said  that  he 
hears  whispers  with  the  same  ease  as  loud-spoken  words 
and  sentences.  He  readily  interprets  familiar  sounds,  and 
when  his  eyes  are  bandaged  and  a  watch,  a  bell,  or  the 
like  impinges  its  sound  upon  his  ear,  he  smiles  and  then 
quickly  writes  the  name.  In  the  same  way  he  interprets 
the  names  and  uses  of  familiar  things  that  make  impres- 
sion upon  his  visual,  tactual,  and  olfactory  apparatus. 
When  shown  a  handful  of  coins  and  requested  to  pick 
out  all  the  five-cent  pieces,  or  twenty-five-cent  pieces, 
or  cent  pieces,  he  does  so  with  accuracy.  He  likewise 
matches  pennies,  according  to  the  heads  or  tails,  dates, 
etc.  When  a  twenty-dollar  bill  is  taken  in  one  hand 
and  a  number  of  bills  amounting  to  eighteen  dollars  in 
the  other,  and  the  patient  asked  which  he  would  rather 


Motor  Aphasia.  205 

have,  there  is  no  hesitation  in  his  decision.  Quality  goes 
before  quantity  with  him  every  time.  On  being  given  a 
number  of  bills  and  coins,  and  asked  to  tell  how  much 
they  aggregate,  he  writes  down  the  correct  answer.  Sim- 
ple columns  of  figures  are  summed  up  with  accuracy  but 
slowly,  and  other  problems  in  mental  arithmetic  are  per- 
formed in  such  a  way  as  to  indicate  the  workings  of  the 
associative  faculties.  He  can  hum  the  national  anthem, 
can  whistle  in  unison  with  another,  and  plays  dominoes, 
cards,  and  penochle  with  a  great  deal  of  skill.  On  being 
asked  if  he  would  like  to  be  able  to  speak  again,  he  looks 
suspiciously  at  his  interlocutor  and  smiles  in  a  most  dis- 
couraged sort  of  a  way ;  but  after  a  moment  he  reaches  for 
the  pencil  and  writes  "Yes."  On  being  told  that  it  is 
very  probable  that  he  could  learn  to  speak  some  words, 
he  quickly  joins  in  the  physician's  effort  to  repeat  after 
him  simple  sounds,  such  as  "  o,  a,  n,"  and  when  he  is 
shown  how  to  place  the  tongue  and  when  the  lips  are 
fixed  in  the  proper  position  for  him  he  makes  intelligent 
efforts  to  produce  the  sounds  into  words,  but  persistent 
effort  to  teach  him  to  speak  has  not  been  rewarded  by 
material  progress. 

This  is  a  case  of  subcortical  motor  aphasia.  It  is  the 
purest  and  most  uncomplicated  that  I  have  ever  seen.  It 
is  not  associated  with  agraphia  or  with  amimia,  and  the 
sensory  side  of  speech  production  seems  to  be  absolutely 
intact.  Whether  or  not  it  was  formerly,  before  he  came 
to  the  hospital,  I  am  unable  to  say,  for  critical  examina- 
tions of  his  speech  defects  had  never  been  made.  His 
case  illustrates  with  great  force  the  fact  that  in  subcor- 
tical motor  aphasia  loss  of  articulate  speech  may  be  the 
only  expression  of  inability  to  project  outwardly  states  of 
mental  content.  He  writes  with  accuracy,  both  sponta- 


206  The  Faculty  of  Speech. 

neously  and  from  dictation.  He  expresses  mental  feel- 
ing by  means  of  mimicry  which  is  very  easy  to  compre- 
hend, but  with  the  one  exception  of  the  word  "  Yes"  and 
a  sound  resembling  "  No"  he  makes  no  use  of  articula- 
tion. His  writing  shows  no  evidence  of  repetition,  of 
transliteration,  or  of  agraphia.  It  shows,  however,  an  un- 
commonly accurate  portrayal  of  cognitions  and  feelings, 
for  one  of  his  class. 

To  summarize  the  clinical  conditions  in  this  patient, 
they  are :  Loss  of  volitional  speech ;  the  images  of  articu- 
lation are  preserved  and  he  responds  to  the  Proust- Licht- 
heim  test.  On  account  of  inability  to  speak,  he  cannot 
repeat  from  dictation.  He  can  hum  the  air  of  a  song,  but 
not  the  words.  He  is  unable  to  read  aloud.  On  the  other 
hand,  there  is  no  alexia  or  dyslexia,  there  is  no  agraphia; 
he  can  write  voluntarily,  from  dictation,  and  from  copy. 
He  comprehends  spoken  speech,  written  speech,  and  ges- 
ture language.  The  word  memory  is  not  disturbed,  the 
intrinsic  speech  mechanism  is  intact ;  none  of  the  word 
memories,  visual,  auditory,  articulatory,  are  in  any  way 
destroyed. 

The  left  motor  area  or  the  projection  fibres  going  out 
from  it  are  destroyed,  and  this  is  indicated  by  the  spastic 
hemiplegia  which  the  patient  has  of  the  right  side  of  the 
body.  The  fact  that  there  are  complete  inability  to  articu- 
late a  sound  and  pronounced  inability  to  co-ordinate  lin- 
guo-buccal  movements,  as  in  whistling,  without  facial 
paralysis,  leads  me  to  the  belief  that  the  lesion  is  of  the 
cortical  Rolandic  area  to  which  are  allocated  the  repre- 
sentation for  the  vocal  cords,  tongue,  lips,  etc.,  and  not 
lower  down  in  the  projection  tracts.  For  if  the  lesion 


Motor  Aphasia.  207 

were  of  the  latter  it  is  probable  that  there  would  not  be 
such  complete  aphemia  as  there  is,  but  that  there  would 
be  pronounced  dysarthria  or  stammering.  In  this  case, 
it  would  seem  that  the  word  impulse  representing  the 
idea  left  the  zone  of  language  properly  and  completely 
formed,  but,  on  being  handed  over  to  the  cortical  execu- 
tive mechanism,  it  could  not  be  started  down  the  emissive 
pathways,  the  projection  tract,  on  account  of  destruction 
of  that  part  of  the  cortex. 

The  next  case,  in  which  I  believe  from  analysis  of 
speech  the  lesion  is  lower  down,  is  as  follows : 

Mrs.  S ,  a  Polish  Russian,  thirty-eight  years  old. 

There  is  nothing  of  interest  or  of  import  in  her  family 
or  previous  personal  history,  with  the  exception  of  the 
event  with  which  her  present  illness  is  associated.  From 
members  of  her  family  it  is  learned  that  she  was  in  per- 
fect health  until  immediately  after  the  birth  of  her  last 
child,  five  years  ago,  when  she  was  stricken  with  an  at- 
tack of  apoplexy,  followed  by  right  hemiplegia  and  inabil- 
ity to  communicate  thought  by  means  of  spoken  language. 
Examination  shows,  as  will  be  seen  hereafter,  that  she  is 
in  possession  of  the  most  complete  understanding  of  every- 
thing that  is  said  to  her,  and  that  she  has  the  faculty  of 
making  manifest  such  understanding  and  her  wishes  by 
means  of  the  most  expressive  gestures.  Her  whole  vocab- 
ulary is  contained  in  two  or  three  words,  which  she  uses 
for  every  occasion. 

What  is  your  name?  A.  Frieda—,  Frieda—,  Frieda- 
Perl.  (With  a  look  of  discouragement)  Ich  kann  nicht. 

How  old  are  you?  A.  (In  a  sing-song  tone.)  Five, 
and  five,  and  five,  and  five,  and  five,  and  five,  and  five 
(and  then  she  holds  up  three  fingers,  at  the  same  time 
smiling  very  knowingly). 


2o8  The  Faculty  of  Speech. 

How  old  did  you  say  you  were?  A.  (Starts  to  repeat 
it.) 

Are  you  thirty-nine?     A.   No. 

Are  you  thirty-eight?  (Quick  as  a  flash.)  Yes  (this 
being  the  number  of  years  indicated  by  the  use  of  the 
seven  fives  plus  three,  reckoned  on  the  fingers). 

Are  you  married?  (In  a  sing-song  way.)  Oh,  yes, 
yes,  yes.  Then  she  begins  repeating,  "  Five,  and  five, 
and  five,  and  five"  in  a  sing-song  way,  and  then  holds  up 
one  finger,  all  of  which  indicates  that  she  wishes  to  say 
that  she  has  been  married  twenty-one  years.  On  being 
asked  if  she  has  been  married  twenty-one  years,  she 
responds  very  quickly  and  accurately,  "  Yes." 

How  many  children  have  you  had  ?  (She  holds  up  one 
finger.)  One?  A.  Yes. 

What  is  your  child's  name?     A.   I  can't  say. 

Is  it  a  girl  or  a  boy?  (Points  to  herself  to  indicate 
that  the  child  is  one  of  her  own  sex. ) 

How  old  is  she  ?  A.  Five,  and  five,  and  five ;  then  she 
holds  up  three  fingers,  which,  of  course,  means  that  her 
daughter  is  eighteen  years  old. 

Is  she  married  ?     A.   Yes. 

What  is  her  husband's  name?  A.  I  can't  say  (ich  kann 
nicht). 

Has  she  children  ?  In  response  to  this  question,  the 
patient  makes  the  most  exquisitely  intelligent  and  ex- 
pressive gestures  that  I  have  ever  seen ;  her  face  is 
wreathed  in  smiles,  she  places  her.  left  hand  over  her 
heart,  and  her  right  hand  a  short  distance  from  the  floor, 
as  if  to  lift  up  the  baby,  and  then  she  carries  the  imagi- 
nary baby  to  her  breast,  caresses  and  kisses  it ;  then  she 
puts  it  down  and  kisses  her  hand  to  it;  and  then  she 
waves  kisses  in  the  direction  of  her  previous  home  in  the 
lower  part  of  the  city.  After  doing  this,  tears  are  seen 


Motor  Aphasia.  209 

welling  up  in  her  eyes,  but  this  condition  is  not  the 
lachrymose  uncontrollable  attacks  of  depressed  emotion, 
such  as  are  sometimes  seen  in  hemiplegia. 

Interpreted,  these  gestures  mean,  in  the  most  inimitable 
way,  that  she  has  recently  become  a  grandmother;  that 
the  little  child  is  just  beginning  to  creep;  that  she  would 
like  to  press  it  to  her  bosom ;  that  it  is  the  embodiment 
of  her  maternal  affection ;  and  her  tears  come  because  she 
is  separated  from  it.  If  it  is  suggested  to  her  that  this 
is  the  proper  interpretation  of  her  gestures  she  gives  the 
most  appreciative  and  grateful  assent.  If  some  other 
interpretation  is  suggested  to  her,  she  laughs  scornfully. 

Tell  me  about  your  sickness.  Oh,  yi,  yi,  yi,  yi,  yi,  yi, 
yi,  vergessen  (forgotten),  kann  nicht  (I  cannot)  friiher 
(before),  weiss  es  nicht  (I  do  not  know),  spater  (later),  in, 
vergessen  (forgotten),  Frieda  Perl  (her  first  name,  to  which 
she  attaches  the  word  "  Perl,"  for  what  reason  I  have  not 
yet  been  able  to  fathom),  finger.  All  this  is  said  in  a 
singing  tone.  After  she  repeats  these  words  over  for 
a  time,  she  ceases  to  speak,  as  if  discouraged  with  her 
own  efforts.  She  then  makes  most  suggestive  gestures 
of  combing  her  hair  and  then  of  toppling  over,  which 
means  that  her  attack  of  hemiplegia  came  on  without 
warning  in  the  morning  five  years  ago,  while  she  was 
combing  her  hair,  that  she  toppled  over,  and  that  she  was 
unconscious  for  quite  a  long  time. 

On  examination  of  the  patient's  physical  condition,  it  is 
seen  that  she  is  a  well-nourished  woman,  that  she  has 
the  gait  and  station  of  one  with  partial  right-side  hemi- 
plegia, and  that  the  remains  of  the  paralysis  are  more 
marked  in  the  right  upper  extremity  than  in  any  other 
part  of  the  body.  The  patient  is  able  to  perform  all  the 
general  movements  of  the  tongue  and  lips,  and  there  is 
no  difficulty  of  swallowing,  no  dribbling  of  saliva,  and 


2io  The  Faculty  of  Speech. 

she  goes  about  and  takes  care  of  herself  as  does  any 
patient  whose,  mental  integrity  is  undisturbed.  As  has 
been  said,  the  language  of  her  emotions  is  not  at  all  im- 
paired, and  she  smiles,  frowns,  laughs,  and  cries,  when- 
ever there  is  cause  for  any  of  these  outward  expressions, 
but  she  does  not  manifest  them  without  cause.  She  under- 
stands all  that  is  said  to  her,  and  detects  with  the  great- 
est readiness  unreasonable  or  ridiculous  statements  or 
speeches.  The  sensory  side  of  her  speech  faculty  is  ap- 
parently intact.  The  patient  has  never  been  able  to  read 
or  write,  but  she  recognizes  the  letters  of  the  Hebrew 
alphabet  and  words  which  form  parts  of  familiar  prayers, 
and  she  recognizes  and  puts  the  proper  interpretation 
upon  pictures.  For  instance,  shown  the  picture  of  a  girl, 
she  smiles,  and  points  to  some  young  female  patient  in 
the  ward,  or  goes  through  the  gestures  mentioned  above 
to  indicate  that  one  of  the  kind  in  the  shape  of  her  little 
granddaughter  is  in  her  own  family.  When  shown  the 
picture  of  a  cow  she  tries  to  pronounce  the  word,  but  when 
she  cannot  she  reaches  for  a  glass  and  by  carrying  it  to 
her  lips  aims  to  indicate  that  the  cow  gives  milk ;  and  so 
on,  with  all  the  objects  or  subjects  with  which  she  is  vis- 
ually familiar. 

Sounds  and  words  apparently  make  natural  and  proper 
impression  upon  her  auditory  peripheral  and  central  ap- 
paratus, and  the  tick  of  a  watch,  the  sound  of  a  bell,  the 
paring  of  an  apple,  the  note  of  a  pianoforte,  are  all  heard 
and  properly  interpreted.  As  I  have  said,  she  is  wholly 
uneducated  from  a  scholastic  standpoint,  and  unable  to 
write.  Naturally,  therefore,  it  is  impossible  to  say  whether 
or  not  there  is  agraphia  or  paragraphia.  We  may  infer, 
however,  that  had  she  been  able  to  write  there  would  have 
been  no  defect  in  the  graphic  representation  of  thought 
except  that  due  to  the  immobility  of  the  right  hand.  It 


Motor  Aphasia.  2 1 1 

is  perhaps  unnecessary  to  state,  after  what  has  been  said, 
that  the  patient  responds  with  alacrity  to  the  ordinary 
commands,  such  as  "  Put  out  your  tongue,"  "  Close  your 
eyes,"  "  Bring  me  a  piece  of  paper,"  and  the  like,  and  con- 
ducts herself  in  every  way  like  a  person  in  the  fullest  pos- 
session of  her  mental  faculties. 

Repeated  examination  of  this  patient,  week  after  week, 
shows  no  material  change  in  the  responses  to  various  tests. 

The  age  of  the  patient,  a  consideration  of  her  previous 
history,  the  physiological  effort  immediately  antecedent  to 
the  attack,  the  mode  of  onset,  duration,  symptoms,  and 
termination  of  the  attack,  and  the  degree  of  physical  and 
mental  recovery  which  followed  it,  all  point  unerringly  to 
an  embolus  of  one  of  the  lenticulo-striate  arteries  as  the 
cause  of  her  apoplexy.  It  is  not  my  purpose  to  pursue 
further  a  discussion  of  this  question  here,  first,  because 
it  is  not  patent  to  the  symptom  complex  of  subcortical 
aphasia,  which  now  interests  us,  and  second,  because  the 
onset  and  course  of  the  hemiplegia  were  typical  of  cere- 
bral embolism. 

A  retrospect  of  her  history  shows  that  in  the  beginning 
there  was  complete  aphemia,  and  that  now,  some  five 
years  later,  the  aphemia  is  still  present,  but  is  not  ab- 
solutely complete.  She  can  articulate  a  certain  number 
of  words;  she  can  use  properly  the  words  "Yes"  and 
"No;"  and  almost  always  the  sentence,  "I  can't  say." 
The  few  words  of  her  vocabulary  are  used  with  conven- 
tional significance;  but  they  are  produced  in  a  sing-song 
fashion,  that  is,  the  sounds  are  intonated  and  the  words  are 
repeated,  and  the  rhythm  of  their  emission  is  irregular. 

Really,  the  most  striking  and  interesting  side  of  her 


2 1 i  The  Faculty  of  Speech. 

possessions  in  the  way  of  projecting  mental  contents  is  her 
ability  to  use  pantomime  so  expressively  and  intelligently. 
It  is  not  necessary,  in  this  connection,  to  say  again  that 
thought  is  expressed  by  movements.  Movements  are 
particularized  in  three  ways,  namely,  by  speech,  by  writ- 
ing, and  by  pantomime,  and  inability  to  express  thought 
by  any  one  of  these  three  ways  is  known  respectively  as 
aphemia,  agraphia,  and  amimia.  In  some  cases  of  apha- 
sia, all  of  these  defects  are  present,  in  others  one  may 
be  complete,  and  the  others  only  partial ;  while  in  sub- 
cortical  motor  aphasia,  of  which  this  case  is  an  example, 
one  of  these  faculties,  oftentimes  two,  are  entirely  spared, 
while  the  third  is  completely  destroyed.  In  this  patient 
it  would  seem  that  the  projection  areas  of  the  cortico- 
nuclear  neurons  which  serve  motor  speech  production  were 
interrupted  by  the  vascular  lesion  that  occurred  five  years 
ago,  but  that  the  cortico-nuclear  neurons  which  conduct 
impulses  that  are  manifest  by  pantomime  have  remained 
intact.  Sufficient  has  been  said  in  speaking  of  the  exam- 
ination of  the  patient  to  show  that  the  associative  faculties 
which  are  the  basis  of  intellectual  activity  have  not  been 
seriously  impaired  in  this  woman,  nor  has  the  internal 
language.  Her  mode  of  answering  questions  into  which 
the  element  of  time  is  interjected  shows  that  she  is  capa- 
ble of  reckoning.  I  might  say  in  this  connection  that  if 
she  were  asked  to  compute  simple  problems  in  mental 
arithmetic  she  would  indicate  the  correct  answer  by  hold- 
ing up  successively  the  fingers  of  the  hand,  or  by  intonat- 
ing, "  Five  and  five  and  five,"  and  so  on,  until  she  ap- 
proached as  nearly  as  possible  to  the  correct  figure  by 
using  the  multiple ;  then  she  would  complete  the  answer 


Motor  Aphasia.  213 

by  holding  up  one,  two,  three,  or  four  fingers  as  the  case 
required. 

The  distinguishing  features  in  these  two  cases  are  that 
in  the  first  there  is  no  agraphia  and  the  patient  responds 
to  the  Proust- Lichtheim  test,  and  in  the  second  there  is 
no  disturbance  of  internal  language.  If  it  be  a  fact  that 
a  lesion  of  any  of  the  speech  centres  entails  some  perver- 
sion of  internal  language  in  every  instance,  these  cases  do 
not  belong  to  the  category  of  cortical  or  true  aphasia. 
They  differ  one  from  the  other  by  the  fact  that  the  first 
patient  is  absolutely  speechless,  and  the  second  can  say  a 
few  words  but  only  in  a  sing-song  manner.  When  she 
says,  "  Fiinf  und  fiinf  und  fiinf  und  funf,"  etc.,  she  does 
not  speak  it,  she  sings  it.  The  other  words  that  she  uses 
are  pronounced  very  imperfectly  and  indistinctly.  It  is 
impossible  to  indicate  this  on  paper,  for  she  speaks  the 
Yiddish  jargon  and  it  has  to  be  translated  into  English 
that  it  may  mean  anything  on  paper;  but  as  a  matter  of 
truth  the  words  that  she  uses  are  very  imperfectly  articu- 
lated. It  is  this  imperfectness  of  articulation  of  words 
that  she  can  say  and  the  sing-song  way  of  making  replies 
that  lead  me  to  believe  that  the  lesion  in  her  case  is  at  a 
lower  level  than  in  the  case  first  enumerated.  That  is,  I 
believe  that  in  the  second  case  the  words  may  get  started 
down  the  projection  tracts  on  their  way  to  be  externalized, 
but  they  meet  with  an  interruption  in  the  shape  of  the 
lesion  at  some  lower  level.  Those  fibres  that  are  not  en- 
tirely severed  allow  the  transmission  of  the  impulses  that 
are  externalized  by  the  patient's  few  words. 

When  the  lesion  causing  subcortical  motor  aphasia  is 
situated  at  a  level  as  low  as  the  internal  capsule,  then  a 


214  The  Faculty  of  Speech. 

diagnosis  can  often  be  positively  made,  not  alone  from  the 
employment  of  the  Proust- Lichtheim  test,  but  from  study 
of  the  trouble  of  articulation.  Such  a  patient  has  all  the 
components  of  internal  language  absolutely  intact,  inclu- 
sive of  the  articulatory  kinaesthetic  images  of  words.  He 
hears,  sees,  writes,  mimics,  and  in  other  ways  gives  evi- 
dence of  intellectual  integrity.  He  is  incapable  only  of 
causing  the  co-ordinate  movements  which  subserve  articu- 
late speech.  He  may  not  be  totally  devoid  of  power  of 
articulation ;  his  incapacity  may  vary  from  simple  slur- 
ring and  elision  of  certain  syllables  and  words,  through 
dysarthria,  dysrhythmia  up  to  complete  anarthria  and 
arhythmia,  and  thus  complete  speechlessness.  This  partial 
loss  of  the  capacity  for  articulate  speech  is  well  illustrated 
by  the  first  case  of  Dejerine  cited  above. 

In  the  conventional  use  of  the  term,  this  condition  is 
aphasia;  but  it  is  not  true  aphasia,  for  true  aphasia  occurs 
only  with  lesion  of  the  area  of  language.  Yet  it  simulates 
true  aphasia  so  closely  that  a  differential  diagnosis  can 
be  made  only  after  very  careful  study.  The  nearer  the 
lesions  to  the  cortex,  the  more  difficult  will  this  differ- 
entiation be  for  such  cases.  All  the  projection  fibres 
coming  from  the  executive  articulatpry  area  are  more 
likely  to  be  involved,  and  with  it  there  may  be  some  func- 
tional perversion  (possibly  transitory)  of  the  zone  of  lan- 
guage. 

The  differentiation  of  cortical  and  subcortical  aphasia 
sometimes  becomes  of  inestimable  importance  from  a 
medico-legal  point  of  view.  For  instance,  a  patient  who 
has  the  symptom  complex  of  motor  aphasia  due  to  a  sub- 
cortical  lesion  may  be  just  as  competent  to  make  a  will 


Motor  Aphasia.  215 

and  dispose  of  his  possessions  as  a  man  who  has  hemi- 
anaesthesia  due  to  a  central  lesion ;  but  a  man  who  has 
cortical  motor  aphasia,  and  thus  a  derangement  of  his  in- 
ternal language,  entailing  some  deviation  from  normal  in 
every  component  of  speech,  be  it  in  hearing,  in  seeing,  or 
in  expressing  himself  (including  writing),  may  be  quite 
incapacitated  from  such  disposition,  according  to  the 
interpretation  of  the  law. 

Cortical  motor  and  subcortical  motor  aphasia  are  both 
almost  invariably  associated  with  right  hemiplegia,  and 
are  dependent  upon  the  same  lesion.1  In  the  cortical 
form  the  hemiplegia  is  apt  to  be  less  complete,  and  the 
spasticity  of  the  paralyzed  parts  great.  Moreover,  it  usu- 
ally follows  immediately  after  the  stroke,  although  it  may 
occur  with  epilepsy,  tumors,  abscess,  foci  of  inflammation, 
or  other  conditions  which  slowly  destroy  Broca's  area. 

1  In  Appendix  II.  a  case  of  cortical  motor  aphasia  is  cited  in  which  there 
was  no  hemiplegia.  It  may  be  of  interest,  or  instructive  perhaps,  to  read  it 
in  connection  with  this  chapter. 


CHAPTER   VI. 

SENSORY  APHASIA. 

I.  General  Considerations.  2.  Sensory  Aphasia:  Word 
Deafness  or  Audit ony  Aphasia,  and  Word  Blindness 
or  Visual  Aphasia.  J.  Subcortical  Sensory  Aphasia. 

As  motor  aphasia  is  used  to  designate  those  disturb- 
ances of  speech  expression  in  which  the  chief  diffi- 
culty is  in  making  speech,  sensory  aphasia,  as  a  term,  is 
applied  to  those  cases  in  which  imperfections  of  language, 
disability  or  inability  to  speak,  are  due  to  interference 
with  the  reception  of  speech  forms ;  that  is,  to  lesion  of 
the  perceptive  areas  of  the  brain  and  the  immediate  in- 
coming and  commissural  pathways  of  such  areas.  The 
perceptive  centres  by  whose  functioning  speech  is  onto- 
genetically  developed  are  the  auditory  and  the  visual,  and 
sensory  aphasia  is  thus  practically  auditory  and  visual 
aphasia,  and  it  is  as  such  that  I  shall  describe  it,  after  a 
brief  introduction  to  the  subject. 

Sensory  aphasia  may  be  defined  as  loss  of  the  under- 
standing of  words,  due  to  interference  with  the  formation 
of  associations  necessary  for  complete  perception.  An- 
atomically speaking,  cortical  sensory  aphasia  might  be  de- 
fined as  aphasia  due  to  lesion  of  the  posterior  part  of  the 
area  of  language,  and  cortical  motor  aphasia  as  due  to 
lesion  of  the  anterior  end  of  this  zone.  The  subcortical 


Sensory  Aphasia.  •      217 

forms  of  each  variety  occur  when  there  is  lesion  of  the 
pathways  which  carry  impressions  into  and  away  from  the 
zone  of  language. 

When  Wernicke  first  described  sensory  aphasia  it  was 
as  a  symptom  complex  characterized  chiefly  by  loss  of 
comprehension  of  words,  heard  and  read,  often  associated 
with  paraphasia  and  agraphia.  Clinically  speaking,  this  is 
what  is  understood  by  the  designation,  and  although  sensory 
aphasia  is  subdivided  into  auditory  and  visual,  it  is  only 
that  the  subject  may  be  easier  of  comprehension  and  more 
in  accordance  with  the  symptoms  that  our  cases  present. 
The  separation  of  sensory  aphasia  into  auditory  aphasia 
and  visual  aphasia  is  quite  natural,  in  view  of  the  fact  that 
physiology  and  pathology  are  in  the  fullest  accord  in 
granting  separate  allocation  to  the  two  functions,  seeing 
and  hearing,  whose  integrity  is  so  essential  to  the  de- 
velopment and  maintenance  of  speech.  As  the  cortical 
representation  of  these  two  functions  is  independent,  it 
follows  that  one  may  be  diseased  without  the  other.  In 
such  case  the  resulting  symptoms  are  predominantly  of 
the  centre  diseased,  but  nevertheless  there  are  always 
some  symptoms  referable  to  the  centre  not  the  seat  of 
lesion,  for  none  of  the  speech  centres  are  autonomous  and 
lesion  in  one  entails  perversion  of  the  function  of  all  the 
others.  In  other  words,  in  order  that  speech  may  be  per- 
fect, whether  it  be  internal  speech  or  external  speech,  it  is 
necessary  that  the  entire  speech  mechanism  be  intact.  For 
the  occurrence  of  a  physiological  reflex  it  is  necessary  that 
the  afferent  tract,  the  centre,  the  efferent  tract,  and  the 
part  in  which  the  reflex  act  is  manifest  be  intact ;  and  if 
any  one  of  them  be  disorganized  the  reflex  act  will  be  cor- 


2 1 8  The  Faculty  of  Speech. 

respondingly  abnormal.  Each  element  entering  into  the 
constitution  of  the  reflex  arc  is  an  entity,  if  one  chooses 
to  call  it  so,  and  each  one  of  its  parts  may  continue  to 
discharge  certain  functions  after  another  part  is  diseased, 
but  it  can  no  longer  contribute  its  share  to  the  perform- 
ance of  a  compound  or  a  conjoint  act  after  such  disease. 
In  the  same  way  speech  becomes  disordered  when  one  of 
the  components  entering  into  the  speech  mechanism  is 
diseased.  Nevertheless,  when  the  auditory  area  is  alone 
the  seat  of  destructive  process,  there  is  no  reason  why  the 
visual  and  articulatory  kinaesthetic  memories  should  not 
remain  intact,  and  so  they  do ;  but  when  memorial  recalls 
from  these  centres  are  intercalated  into  the  speech  circle, 
the  auditory  link  is  missing,  and  the  circuit  cannot  be 
completed ;  the  result  is  disturbance  of  speech,  referable 
particularly  to  the  hearing,  because  that  is  the  element 
that  is  wanting.  Moreover,  as  the  primary  revival  of  words 
takes  place  in  the  vast  majority  of  peoples  by  the  initia- 
tive of  the  auditory  centre,  when  this  is  diseased  internal 
speech  is  very  defective. 

The  blood-vessel  supplying  the  zone  of  language  is  the 
left  middle  cerebral  artery,  the  so-called  Sylvian  artery. 
Lesion  of  different  parts  of  its  course  entails  different  re- 
sults. Disease  of  the  anterior  part  and  branches  is  apt  to 
cause  motor  aphasia ;  of  the  posterior  part  and  branches, 
sensory  aphasia.  In  the  beginning  the  sensory  aphasia 
may  appear  to  be  equally  of  both  the  auditory  and  the  vis- 
ual centres,  but,  as  time  goes  on  and  nature  strives  to  over- 
come the  lesion,  the  affection  of  one  of  these  centres  of  lan- 
guage may  be  less  serious  than  that  of  the  other,  and  there- 
fore the  symptoms  referable  to  it  will  be  soon  cleared  up. 


Sensory  Aphasia.  219 

The  symptoms  referable  to  the  other  sensory  centre  may  be 
caused  by  lesion  of  a  branch  of  the  vessel  going  directly 
to  that  centre,  and  therefore  these  symptoms  are  continu- 
ous and  persistent.  Thus  it  is  readily  seen  that  a  degree 
of  auditory  aphasia  and  visual  aphasia,  or  word  deafness 
and  word  blindness,  as  they  are  unfortunately  called,  are 
frequently  coexisting  phenomena.  The  predominance  of 
the  one,  or  the  apparent  individual  occurrence  of  the  other, 
depends  upon  the  seat  and  the  intensity  of  the  lesion. 
Many  cases  of  sensory  aphasia,  especially  those  due  to 
vascular  lesion,  have  in  the  beginning  symptoms  pointing 
to  implication  of  both  the  auditory  and  the  visual  centres; 
yet  after  the  condition  has  existed  for  a  time  the  symptoms 
referable  to  one  of  these  centres  may  be  reduced  or  even 
become  latent,  while  those  referable  to  the  other  centre  per- 
sist and  dominate  the  clinical  picture.  Thus  auditory 
aphasia  or  word  deafness  and  visual  aphasia  or  word  blind- 
ness are  differentiated  remains  of  one  and  the  same  sensory 
aphasia. 

Sensory  aphasia  possesses  certain  very  definite  general 
features,  which  I  propose  to  enumerate  briefly  before 
taking  up  the  separate  discussion  of  auditory  aphasia  and 
visual  aphasia.  These  general  features  are  in  many  ways 
materially  different  from  the  general  features  of  motor 
aphasia,  and  they  are  explained  by  the  location  and  rela- 
tionships of  the  different  centres.  Motor  aphasia  is  al- 
most invariably  associated  with  hemiplegia,  while  sensory 
aphasia  is  rarely  accompanied  by  hemiplegia  unless  the 
lesion  is  a  most  extensive  and  severe  one.  In  the  case  of 
motor  aphasia  this  is  easily  explained  by  the  proximity  of 
the  convolution  of  Broca  to  the  motor  centres  in  the 


220  The  Faculty  of  Speech. 

Rolandic  region  and  to  the  motor  projection  tract.  On 
the  other  hand,  if  the  lesion  be  confined  to  the  posterior 
part  of  the  zone  of  language,  the  cortical  motor  area  and 
the  projection  tract  constituted  by  its  central  axones  may 
be  entirely  spared.  Compared  with  motor  aphasia,  sen- 
sory aphasia  is  relatively  more  often  associated  with 
lesions  that  are  not  primarily  vascular  in  origin.  In 
other  words,  it  is  more  likely  to  occur  with  encephalitis, 
with  tumors,  with  injury,  and  with  certain  degenerative 
diseases  of  the  brain ;  and  thus  its  evolution  is  often  very 
different  from  that  of  motor  aphasia.  Whereas  the  former 
is  almost  always  abrupt,  and  consequent  on  an  apoplectic 
stroke  which  usually  entails  more  or  less  prolonged  loss 
of  consciousness,  sensory  aphasia  not  infrequently  unfolds 
itself  slowly,  and  even  when  due  to  a  vascular  lesion  it 
oftener  comes  on  progressively  or  in  repeated  accessions 
than  does  motor  aphasia. 

Another  very  striking  feature  of  sensory  aphasia  is  that 
in  the  beginning  it  is  the  aphasia  of  comparative  speech- 
fulness,  while  motor  aphasia  in  the  beginning  is  usually 
absolute  speechlessness.  Sensory  aphasia  is  characterized 
by  logorrhoea,  motor  aphasia  by  alogia.  Then  the  career 
of  sensory  aphasia  is  most  instructive.  The  unfortunate 
patient  starts  in  with  his  senseless  loquacity,  and  week 
after  week,  sometimes  day  by  day,  one  notes  the  shrink- 
age of  his  useless  vocabulary,  through  the  stages  of  bab- 
bling, of  lalling,  and  of  echoing,  down  to  absolute  mutism 
as  complete  as  that  produced  by  total  destruction  of  the 
articulatory  kinaesthetic  area.  The  course  of  a  sensory 
aphasic  may  be  compared  to  that  of  a  runaway  engine. 
Some  accident  opens  the  throttle  during  the  absence  of 


Sensory  Aphasia.  221 

the  driver,  and  away  it  flies  without  regard  to  destination, 
to  danger,  to  results.  Gradually,  as  its  steam  becomes  ex- 
hausted, its  pace  becomes  slower,  it  becomes  less  boister- 
ous, it  is  more  easily  overtaken,  until  finally  the  last  atom 
of  steam  is  exhausted  and  it  comes  to  a  dead  halt.  There 
is  nothing  to  stir  it  up  and  start  it  on.  It  stands  ready, 
however,  at  any  moment  to  be  made  a  useful  agency ;  it 
requires  but  coals  and  water.  If  it  remain  unused 
for  a  long  time,  rust  and  other  accompaniments  of  time 
so  incapacitate  it  that,  even  if  these  elements  be  given 
to  it,  it  is  no  longer  a  useful  agent,  and  it  stands  a  useless 
wreck  of  its  former  self,  a  wreck  induced  by  loss  of  the 
agencies  necessary  to  drive  it,  all  dating  back  to  the  acci- 
dent that  opened  the  throttle. 

It  is  the  same  with  the  patient  who  has  had  a  lesion 
of  his  auditory  speech  centre  which  is  sufficient  to  derange 
it  without  completely  destroying  it.  From  the  beginning 
of  the  person's  ability  to  speak  this  centre  has  exercised 
the  influence  of  a  director-general  over  the  articulatory 
speech  centre,  inhibitory  and  excitatory.  Now  this  in- 
fluence is  taken  away.  The  result  is  that  all  the  inhibi- 
tory influence  is  destroyed  by  one  blow,  and  the  work 
of  years  of  experience  on  the  part  of  the  articulatory 
centre  in  the  endeavor  to  become  a  centre  of  the  primary 
reviver  of  words  begins  to  dissipate  like  a  corundum  wheel 
when  breaking,  and  the  result  is  logorrhoea.  After  this 
automatic  storehouse  (which  is  always  small,  even  in  the 
most  expert  linguist  and  most  highly  educated  man)  is  ex- 
hausted, the  vocabulary  begins  to  shrink,  and,  as  the  centre 
which  has  always  acted  as  the  stimulator  in  the  memorial 
recall  of  words  is  destroyed,  the  patient  gradually  approxi- 


222  The  Faculty  of  Speech. 

mates  mutism,  although  the  articulatory  kinaesthetic  centre 
is  itself  intact,  ready  to  do  its  work  on  the  reception  of  the 
proper  incentive.  But  if  this  incentive  has  been  long  with- 
held, like  the  engine  that  becomes  incapacitated  by  rust 
and  other  ravages  of  time,  it  will  be  incapable  of  doing  it, 
even  though  such  incentive  should  be  given  to  it  long 
after.  This  is  but  another  bit  of  evidence  in  favor  of  the 
interactivity  of  the  different  speech  centres  and  against 
the  autonomy  of  any  one  of  them. 

Patients  with  sensory  aphasia  are  very  rarely  reduced  to 
a  condition  of  mutism  by  such  lesion  alone,  because  de- 
struction of  the  auditory  centre  is  rarely  complete.  When 
the  lesion  of  the  auditory  centre  is  slight,  the  most  strik- 
ing abnormality  in  voluntary  speech  is  the  inability  to  use 
words  with  their  proper  signification,  although  the  words 
that  are  used  are  articulated  with  as  much  clearness  and 
distinctness  as  in  the  normal  state.  The  patient  may 
utter  words  that  are  entirely  the  opposite  of  those  which 
he  intended  to  use.  No  more  striking  example  of  this  can 
be  given  than  a  reference  to  the  history  of  a  lady  cited 
by  Trousseau, '  who,  arising  to  greet  a  visitor,  would  with 
courteous  bow  and  apparent  welcome  say  in  the  most 
matter-of-fact  way,  "  Pig,  brute,  stupid  fool,"  which  when 
interpreted  by  one  of  her  family  meant,  "  Madame  begs 
you  to  be  seated."  Happily  the  misuse  of  words  does  not 
often  take  this  decidedly  frappant  form.  It  may  be  ap- 
parent only  by  a  change  of  position  of  words  in  a  sentence, 
or  by  the  use  of  one  word  for  another  that  has  a  somewhat 
similar  sound  or  beginning.  The  condition  is  one  that 
admits  of  ready  explanation  :  the  sensory  centres  being  de- 

1  Trousseau  :  "Clinical  Medicine,"  fourth  edition,  vol.  ii.,  p.  674. 


Sensory  Aphasia.  223 

stroyed,  their  images  can  no  longer  be  evoked  to  act  as  a 
check  or  control  on  the  articulatory  centre,  the  images  in 
which  are  always  evoked  before  the  thought  that  is  to  be 
externalized  can  be  expressed. 

The  defect  of  speech  known  as  "  jargonaphasia"  occurs 
oftentimes  with  sensory  aphasia.  This  may  be  considered 
a  degree  of  paraphasia,  although  the  latter  is  properly 
applied  to  a  condition  in  which  words  are  used  in  an  incor- 
rect sense.  Jargonaphasia  consists  of  the  production  of  a 
jumble  of  words  all  forged  into  one,  the  syllables  of  which 
may  be  articulated,  but  the  words  have  no  similarity  to 
words  as  usually  spoken.  Indeed,  so  wholly  dissimilar  are 
they  that  some  cases  of  jargonaphasia  have  been  con- 
sidered evidence  of  a  supernatural  influence  manifesting 
itself  in  the  sudden  acquisition  of  a  language  undecipher- 
able by  the  most  profoundly  versed  in  strange  tongues. 

Reports  of  these  cases  not  infrequently  find  their  way 
into  newspapers,  and  excite  great  attention  and  are  much 
marvelled  at  by  the  laity.  They  are  oftentimes  investigated 
by  committees  made  up  of  men  imbued  with  praiseworthy 
scientific  zeal,  but  oftener  by  persons  who  have  exhausted 
their  interest  in  things  that  conform  to  the  established 
laws  or  courses  of  nature  and  who  find  inclination  only  in 
the  supernatural.  Jargon  speech  is  occasionally  an  accom- 
paniment of  disordered  cerebration  dependent  upon  altered 
states  of  consciousness  attending  acute  sthenic  and  asthenic 
states. 

It  is  not  alone  in  spontaneous  speech  that  these  perver- 
sions are  manifest ;  they  are  as  evident  when  the  patient 
attempts  to  repeat  what  he  hears  (indeed  oftentimes  very 
much  more  so,  particularly  if  the  patient  is  partially  word 


224  The  Faculty  of  Speech. 

deaf).  In  singing  also  the  condition  of  paraphasia  and 
even  of  jargonaphasia  is  sometimes  very  striking.  The 
patient  remembers  and  is  able  to  hum  the  air  of  a  familiar 
tune,  but  the  words  that  he  attempts  to  fit  to  it  have  no 
sense,  no  propriety,  no  reason.  The  occurrence  of  para- 
phasia and  of  jargonaphasia  on  reading  aloud  is  also  very 
striking,  but  as  this  subject  will  be  considered  in  more 
detail  under  the  subdivisions  of  sensory  aphasia — auditory 
and  visual  aphasia — I  shall  merely  make  mention  of  it  here. 
Not  secondary  in  importance  to  the  information  that 
may  be  obtained  from  a  study  of  articulate  speech  is  that 
which  is  to  be  had  from  an  examination  of  the  spontaneous, 
dictated,  and  copied  writing.  Patients  with  pronounced 
sensory  aphasia  are  not  usually  hemiplegic,  so  that  tests  for 
defects  of  writing  can  be  undertaken  without  trouble  if  the 
patient  be  made  to  comprehend  what  is  wanted.  Defects  in 
writing  are  most  striking  when  visual  aphasia  is  the  prom- 
inent feature  of  the  sensory  aphasia,  although  they  occur 
in  every  case  of  sensory  aphasia.  The  degree  to  which 
spontaneous  writing  may  be  preserved,  or  lost,  in  sensory 
aphasia  varies  with  the  patient,  the  seat,  and  the  intensity 
of  the  lesion.  Oftentimes  there  is  preserved,  even  in  cases 
of  genuine  visual  aphasia,  the  ability  to  write  a  few  words 
spontaneously,  such  as  the  patient's  name,  address,  the 
name  of  some  member  of  his  family,  and  possibly  a  few 
other  words  ;  but  even  in  the  production  of  these  the  patient 
gets  the  surname  following  on  the  family  name,  and  in 
other  ways  shows  the  condition  known  as  paragraphia.  If 
the  patient  has  destruction  of  the  angul'ar  gyrus,  there  will 
be  practically  total  agraphia,  because  he  cannot  revive  the 
visual  memories  that  are  necessary  to  be  evoked  in  order 


Sensory  Aphasia. 


22=; 


that  the  mobile  part  of  the  body  carrying  the  pen  may  be 
directed  by  the  thought  to  inscribe  them.  If  the  lesion 
is  principally  a  destruction  of  the  auditory  area,  there  will 
be  absolute  inability  to  write  from  dictation;  and  even 
though  writing  spontaneously  may  be  preserved  to  a  very 
limited  extent,  the  words  or  sentences  produced  will  be 
markedly  disordered  in  their  arrangement. 

Writing  after  copy  is  preserved  in  every  case  of  genuine 
sensory  aphasia,  but  the  patient  copies  in  a  way  that  at 
once  puts  the  stamp  of  his  infirmity  upon  his  work.  He 
copies  letters  the  way  a  beginner  does  a  drawing,  line  for 
line,  curve  for  curve,  angle  for  angle,  and  makes  an  exact 
reproduction  of  what  is  before  him  in  the  same  manner 
as  does  an  engraver  or  a  forger  of  a  man's  signature. 
These  variations  in  writing  will  be  discussed  particularly 
under  visual  aphasia,  in  which  variety  of  sensory  aphasia 
they  are  most  pronounced. 

I  shall  cite  the  following  case  as  a  typical  example  of 
sensory  aphasia,  even  though  the  symptoms  were  predomi- 
nantly referable  to  that  subdivision  of  sensory  aphasia 
known  as  visual  aphasia.  It  appears  to  me  much  more 
instructive  to  give  accurate  reports  of  interviews  with 
such  a  patient  than  merely  to  state  the  results  of  such  ex- 
aminations. These  reports  demonstrate  more  conclusively 
than  can  any  description,  the  shortcomings  of  speech  as 
they  really  exist.  This  case  has  been  of  great  interest  to 
me  as  one  offering  difficulties  of  interpretation,  and  I  have 
many  stenographic  reports  of  interviews  with  the  patient, 
two  or  three  of  which  I  shall  now  present. 

L.    B ,  female,   thirty-nine  years  old.     Said  to  be 

married.      Admitted  to  my  wards  in  the  City  Hospital, 
15 


226  The  Faculty  of  Speech. 

July  8th,  1896.  History:  One  year  ago  on  awaking  in 
the  morning  she  could  not  move  the  right  side.  The  lower 
extremity  was  not  so  helpless  as  the  upper.  Since  that 
time  she  has  not  been  able  to  talk  understandingly.  About 
eight  or  nine  months  later  she  had  an  epileptic  attack,  and 
since  then  she  has  an  attack  about  once  a  month.  Practi- 
cally nothing  is  known  of  this  patient's  history.  The 
facts  just  mentioned  were  obtained  from  the  registrar  of 
the  hospital,  to  which  she  had  been  taken  immediately  after 
the  beginning  of  her  illness.  These  facts  were  given  by 
the  individual  who  brought  her  to  the  hospital.  Since  she 
has  been  in  the  City  Hospital  we  have  not  been  able  to 
find  out  anything  about  her  from  herself,  nor  has  any  one 
been  to  visit  her  from  whom  such  information  could  be 
obtained.  In  discussing  the  case  I  shall  limit  myself, 
therefore,  to  the  results  of  examination. 

A  general  survey  of  the  patient  shows  that  she  is  able 
to  walk  without  the  aid  of  a  stick  ;  she  swings  and  drags  the 
right  leg  and  foot,  not  in  a  characteristic  hemiplegic  way, 
yet  with  a  considerable  paresis  and  spasticity.  The  right 
upper  extremity  is  in  a  state  of  contracture  and  very 
nearly  completely  paralyzed.  There  is  no  involvement  of 
the  face  or  cranial  nerves.  To  convey  a  proper  idea  of 
her  speech  disturbance,  I  shall  give  a  stenographic  report 
of  a  few  examinations. 

Examination,   September  ^.th. 

What  is  your  name?  m'm'm'y  name,  m'name's  Samp- 
son, my  name's's— I  don't  know.  I  can't  tell  that. 

You  heard  the  doctor  read  the  name  ?     No,  that  I  know. 
Is  your  name  Lucy  Brown  ?     Yes. 
Is  your  name  Lizzie  Brown  ?     No. 
What  is  your  name  ?      Lucy. 
Lucy  what?      I  can't  say. 


Sensory  Aphasia.  227 

Is  it  Lucy  Black  ?     No. 

Is  it  Lucy  Brown  ?     Yes. 

How  old  are  you?  I  can't  tell  you,  mu  mother,  my 
mother,  my  g'mother  go. 

Are  you  twenty  ?     I  wouldn't  say. 

Are  you  more  than  twenty  or  less  than  twenty?  Oh, 
yes;  twenty-one,  twenty-two;  I  had  children  you  know. 

Are  you  forty  ?     Oh,  no. 

You  are  seventy-five  ?     Yes,  ma'm. 

Is  your  mother  living?     Yes. 

When  did  you  see  her  last  ?  She  comes  on  the  first 
m'm'mth. 

Was  she  here  the  first  of  this  month  ?  No,  the  last  of 
the  month. 

Are  you  older  than  your  mother?  I  can't  tell  that 
much. 

Is  your  mother  twenty  ?  (Putting  hand  to  throat)  I  can't 
tell  that  much. 

Is  she  fifty  ?     Of  course  I  can't — boys — got 

Are  you  married?  Yes,  I'm  married  about  o'o'o' — can't 
call  it  now. 

How  long  have  you  been  married?  This  boy — twenty- 
one — boy. 

How  long  have  you  been  married?  I  told  you,  I 
couldn't  tell  you  —  I  couldn't  tell;  sometimes  my 
speech 

Why  can't  you  tell  me?     What?  (in  surprised  tone). 

Why  can't  you  tell  me?  Married  I  tell  you,  please 
(pointing  toward  city)  mother-care. 

Here  she  began  to  talk  of  her  paralyzed  side— "My 
hand  s'clame  [lame]  sometimes  s'clame,  sometimes 
strong." 

I  do  not  know  yet  whether  you  had  one  child  or  twenty  ? 
I  have  had  two. 


228  The  Faculty  of  Speech. 

Do  you  understand  all  I  say  to  you  ?  Oh,  me.  Why 
yes,  ma'm ;  I  was  sleeping,  that's  all. 

Where  are  your  children  ?  Boy  and  a  girl,  boys,  boys, 
girls. 

How  big  are  they  ?     One  boy  is  dead. 

How  big  is  the  other?     Twenty-one. 

That  is  right,  is  it  not  ?     Yes,  sir,  right. 

How  long  have  you  been  in  the  hospital?  Well,  I 
think  it  is  two  months,  I  can't  tell,  Miss  Buckley  (the 
nurse)  knows. 

Have  you  been  here  a  year?     Oh^  no,  sir;  no,  sir. 

Where  did  you  live  before  you  came  here?  Its,  its, 
its,  in  though  its,  its — I  can't  tell  it  (in  despair). 

Where  do  you  live  ?  I  can't  tell  you,  but  I  can  tell 
you  tame. 

Do  you  remember  how  the  house  looked?  Oh,  yes,  sir; 
yes,  sir. 

Would  you  know  it  again  if  you  saw  it  ?  Yes,  sir ;  yes, 
sir. 

Can  you  remember  the  house  next  door?  I  don't 
know,  I  think  so. 

Can  you  remember  how  your  mother  looked?  Yes, 
ma'am ;  my  m'm'm'oth  other  was  lighter  woman. 

Can  you  remember  the  sound  of  her  voice?  Mercy, 
yes ;  oh,  yes. 

What  was  it  like  ?     White  woman. 

What  was  it  like  ?  What  do  you  mean  ?  My  mother 
was  a  white,  my  mother  was  a  white,  light  woman. 

Can  you  remember  the  scund  of  a  bell  ?     Oh,  I  guess  so. 

Can  you  imagine  that  you  hear  a  bell  now  ?     No. 

What  is  a  voice  ?     Voice,  voice. 

Yes;  is  my  voice  like  the  voice  of  that  gentleman? 
(Smiles.)  Voice,  voice. 

Have  you  ever  heard  that  word  before  ?     No  answer. 


Sensory  Aphasia,  229 

I  then  spell  v-o-i-c-e  and  ask  her  to  repeat  it,  but  she 
cannot. 

When  she  tries  she  says  p-u-c-c-b. 

You  can  say  that  pretty  well  ?  Yes — I  can't  once  in  a 
while,  I  have  to  suffer. 

Do  you  know  the  letters  of  the  alphabet  ?  I  can  say 
them. 

Say  them !  C,  c,  c,  no,  no,  is  that  right  ?  C,  u,  t,  v, 
u,  c,  o,  n,  u,  p,  e,  u,  t,  m,  n,  o,  t,  c,  t,  o. 

Does  the  alphabet  not  begin,  a,  b,  c,  etc.  ?    Yes,  that's  it. 

Now  let  me  hear  you  repeat  the  letters  of  the  alphabet 
after  me.  A?  u.  B?  c.  C?  u.  D?  w.  E?  w.  F? 
i.  G?  c.  H?  h.  I?  i.  J?  j.  K?  k.  L?  o.  M? 
i.  N  ?  u.  -  O  ?  o.  P  ?  u.  O  ?  yaw.  R  ?  r.  S  ?  t.  T  ? 
a.  U?  t.  V?  u.  W?  w.  X?  x.  Y?  a.  Z?  c. 

You  recognize  that  the  alphabet  starts  off  a,  b,  c. 
Yes.,  sir,  I  recognize  but  I  can't  say  them,  that's  all. 

It  is  noticed  that  she  watches  very  closely  the  lips  of 
her  questioner. 

Test  for  Recognition  of  Objects  and  Naming  Objects. 

Holding  up  a  watch.     Clock. 

Chain?     Clock,  it's  a  clock. 

Key?  It's  a  clock  (said  very  hesitatingly  and  starts  to 
correct  herself  after  the  word  is  partly  out,  but  at  last  lets 
it  go). 

Holding  up  another  and  more  typical  key?     It's  a  key. 

Pencil?  'S'key,  it's  what's  its  name,  can't  tell  it  now. 
It's  a  clock,  can't  tell  it  now. 

Knife  ?      Knife. 

A  roll  of  bills  ?      It's  a  dollar. 

A  two-dollar  bill  ?      I  can't  tell,  a  dollar. 

A  twenty-dollar  bill?  A  dollar.  Tain't,  can't  do  it 
now;  I  know  it  but  I  can't  do  it  now. 


230  The  Faculty  of  Speech. 

Count  on  your  fingers  how  many  dollars  this  is  (showing 
five-dollar  bill).  Doesn't  understand  and  cannot  be  made 
to,  and  even  after  I  show  her  how  to  do  it  and  illustrate 
what  I  mean  she  cannot  do  it.  Once  she  recognized  and 
named  a  five-dollar  note.  Although  she  seemed  to  know 
the  value  of  different  denominations,  she  could  not  pick 
out  the  money  when  bills  were  called  by  face  notation. 

Match  box  ?     Match  box. 

Cigar?     P-p-five,  pipe. 

Is  it  a  pipe  ?      (With  emphasis)  No,  sir. 

It  is  a  cigarette  ?     Oh,  no. 

It's  a  cigar?     Yes,  it's  a  cigar. 

What  am  I  doing  now  (lighting  a  match)  ?  Match, 
turning  it  up,  lighting. 

How  old  do  you  think  I  am?     I  don't  know. 

Eighty- six?     (Scornfully)  Oh,  no. 

How  many  eyes  have  I  ?     Two. 

What  is  the  color  of  my  beard  ?     No  answer. 

Black?  No.  Yellow?  No.  Green?  W'w'ee,  I 
can  call  it,  but  I  can't  say  the  name. 

Is  it  red?     Y-e-s  (doubtfully). 

What  day  of  the  week  is  it  ?     Wesday  (it  is  Sunday). 

What  day?     W-e-s — ,  yes,  sir,  Sunday. 

What  do  you  do  on  Sunday?     Sleep. 

Are  you  tired  ?     Oh,  no,  no,  sir ;  oh,  no. 

Can  you  move  your  right  hand  ?     That  one  (pointing). 

Apparently  she  cannot  tell  right  from  left  with  ac- 
curacy. 

(Shown  a  picture  of  a  man.)  What's  that  ?  (Hesitates.) 
Is  it  a  cow  ?  Oh,  no. 

Is  it  a  woman  ?     It's  a  man. 

(Shown  a  picture  of  a  woman.)      Sat's  boy. 

Why,  that  is  a  woman.     Yes,  I  say  it's  a  boy. 

(Shown  some  letters,  words,  a  book.)     Points  at  them 


Sensory  Aphasia.  231 

all  indiscriminately,  yet  still  she  seems  to  recognize  some 
difference  between  them. 

(Testing  letters.)  A?  u.  N?  o.  H?  c.  E?  t. 
R?  r.  S?  r.  E?  t.  M?  c.  I?  _.  N?  — 
E?  r.  W?  n. 

What  did  you  have  for  breakfast  ?  (No  answer,  seems 
to  be  thinking.) 

Stewed  kidney  (most  improbable)  ?     Oh,  no. 

At  what  hour  do  you  dine,  as  a  rule,  Lucy?  (Greeted 
with  laughter.) 

What  do  you  like  to  eat?     I'm  not  pertickler. 

Test  for  hearing.  A  tuning-fork  held  to  the  ear  seems 
to  annoy  her,  as  if  there  was  great  hyperaesthesia  of  hearing. 
She  can  detect  a  bell  and  the  jingle  of  coins  in  one  ear 
as  well  as  in  another,  but  she  cannot  say  what  they  are. 
She  hears  the  lowest  whisper  and  apparently  comprehends, 
and  if  one  says  she  does  not  she  assures  him  that  she 
does.  Calls  a  watch  a  clock  when  put  to  ear.  She  could 
not  tell  the  time,  but  seemed  to  recognize  the  error  if  one 
said  it  was  a  different  hour  than  indicated  by  watch. 

(A  cat  walks  across  the  floor).  (Suddenly)  Lucy,  what 
is  that?  (Flabbergasted.)  Is  it  a  dog?  Oh,  no,  no,  sir. 
Is  it  a  cat?  Yes,  sir.  What  kind  of  a  cat?  (Smiles.) 

Lucy,  do  you  take  in  washing  here  ?     No,  sir,  not  here. 

Do  you  drink  beer?  Once  in  a  while.  Whiskey? 
No,  sir. 

What  is  your  husband's  name?     Lucy  Brown. 

There  is  no  tone  deafness  and  she  can  hum  tunes  in 
unison  when  some  one  whistles ;  can  detect  tunes  but  can- 
not say  what  they  are. 

A  knife,  a  pencil,  a  tuning-fork,  a  spool  of  thread,  a 
book,  a  pair  of  scissors,  a  small  bell  and  a  penholder  were 
put  in  a  row  in  front  of  her,  and  she  was  asked  to  pick 
them  up  as  their  names  were  called.  She  did  this  with 


232  The  Faculty  of  Speech. 

considerable  accuracy,  particularly  after  she  had  done  it 
once  or  twice.  In  the  beginning  there  was  some  hesita- 
tion, a  searching  look  directed  toward  me,  as  if  to  ask, 
"Is  it  right?"  and  a  clumsiness  in  picking  them  up,  but 
she  soon  selected  them  without  mistake  or  appreciable 
uncertainty. 

Examination,  September  i^tli. 

What  is  your  name?  Well,  tell  him,  m'u  mame  can't 
you  (last  addressed  to  nurse). 

What  is  your  name?     I  can't,  can't,  can't  tell  it  now. 

Why  not  ?  I  can't,  I  can't,  my  name  is  oh,  o-,  o-,  o-, 
o-,  I  can' . 

How  old  are  you?  Ma'  mother's  name,  my  mawth' 
name  is  ma'name. 

How  old  are  you  ?     My  mother  got  it  down. 

Can't  you  tell  me?     No,  ma'am. 

Have  you  a  father  and  mother?  My  father  is  dead, 
my  mother  is  dead. 

What  was  your  father's  name  ?     Reilly. 

His  first  name?     Can't  tell  that. 

Your  mother's  name?  M'a  mother,  Margaret  Reilly 
(bit  off). 

Are  you  Irish?  I  don't  know,  but  that  is  my  name 
though. 

What  is  your  name?  M'm'ma  name  is — I  can't  tell 
you.  I  can't  call  it.  I  know  what  it  is  though. 

Is  it  Lucy  Brown?     Yes,  sir  (slowly). 

Did  you  ever  go  to  school  ?  N'o,  not  much ;  I  used  to 
t'k  washing. 

Could  you  read?  Yes,  ma'm  (with  a  glib,  cock-sure 
manner). 

Could  you  read  ?     Little  bit. 

Could  you  read?     Write,  oh,  no,  sir;  no,  sir,  no. 


Sensory  Aphasia.  233 

Are  you  married  ?     No,  I  told  you  yes. 

Were  you  married?     Yes,  sir;  two  children. 

What  was  your  husband's  name  ?     Sampson. 

His  first  name  ?     I  can't  call  that  name,  but  I  can  say  it. 

Is  he  living?  Yes,  ma'am,  but  I  don't  know  where  he 
is  tho'. 

How  long  were  you  married?  Two  children,  I  can't 
catch  that. 

What  were  your  children?     Two  boys. 

You  told  me  the  other  day  they  were  a  boy  and  a  girl. 
No,  sir,  I  didn't. 

I  beg  your  pardon,  you  did.  I  did  not  (beginning  to 
cry). 

What  was  your  first  boy  called  ?  Sampson,  after  his 
mother. 

The  second  boy  ?  Little  boy  was  dead,  was  dead  any- 
how. 

What  do  you  mean  by  that  ?     I  can't  tell. 

Was  he  born  dead  ?     Yes,  sir. 

How  long  is  it  since  you  had  a  child?  I  can't  say,  I 
can't  call ;  fo',  fo'  years,  I  can't  call  it— but  anyhow  my 
boy,  ah,  u,  oh,  ah  (sort  of  a  re  very). 

Will  you  count  for  me?  1—2—3—4—5 — 6—7?  9 
—  1 1  —  i  j_  _I  can't. 

What  is  that  figure  (large  4)  ?     No  answer. 

Same  for  other  figures. 

(Showing  coins)  What  is  that?     Money. 

How  much  is  that?  Five  cents  (right).  That? 
Twenty-five  cents  (right). 

Please  pick  out  a  dime  ?     Selects  a  penny. 

Pick  out  a  ten-cent  piece  ?     Does  it  correctly. 

Pick  out  a  five-cent  piece?     (Picks  out  a  ten.) 

(Showing  two-dollar  bill)  How  much?  I  can't  tell,  I 
can't  call  it. 


234  The  Faculty  of  Speech. 

Is  it  money?     Yes,  but  I  can't  call  it. 

Is  it  a  five-dollar  bill  ?  Yes,  I  know  it  now,  it's  a  one- 
dollar  bill;  no,  it's  a  five-dollar  bill,  yes. 

(Holding  up  key)  What's  that?     Key. 

(Penknife.)      (After  some  hesitation)  Knife. 

(Pencil.)      Key — isn't  it ;  no,  was  do  you  do  with  it  ? 

Interlocutor  recites  first  line  of  Longfellow's  "  Bridge," 
also  Lord's  Prayer,  and  asks  her  to  repeat  the  first  line, 
then  half  a  line  at  a  time.  It  is  absolutely  impossible,  she 
makes  the  mouth  go  and  occasionally  makes  an  audible 
sound,  but  in  no  way  repeats. 

Say  birds  ?     Words. 

Rat?      Cat.      Mother?     Mother.      Steamer?     Simmer. 

Kettle?     (In  amazement,  and  does  not  repeat.) 

Says  wasin  for  basin,  richer  for  pitcher,  and  in  other 
ways  simulates  the  sounds  of  words. 

A  number  of  familiar  things  are  spread  out  before  her, 
and  she  is  requested  to  pick  them  up  as  their  names  are 
called.  Pick  up  the  key?  Picks  up  scissors.  Spoon? 
Correct.  Glass?  Correct.  Hair  pin?  Correct.  Look- 
ing-glass? Pincushion.  Pencil?  Correct.  Key?  Knife. 
Lock?  Bell.  Thimble?  Correct.  Looking-glass?  Fum- 
bles pin  cushion,  then  picks  up  mirror.  (This  is  in 
marked  contrast  to  the  successful  efforts  of  the  last  ex- 
amination.) 

I  then  said  to  the  house  physician  that  she  had  mistaken" 
the  pincushion  for  the  mirror  before,  and  then  she  began 
to  say  something  very  inco-ordinate,  like  "  I  said,  you,  well, 
some,  befo',"  etc.,  all  of  which  might  be  construed  as  an 
explanation  of  her  failure  to  pick  things  up  properly. 
There  was  marked  confusion  of  names  of  things.  After 
she  had  picked  them  up  once,  she  seemed  to  be  able  to  do 
it  more  accurately  the  second  time,  but  after  picking  them 
up  a  number  of  times  she  got  more  confused. 


Sensory  ApJiasia.  235 

She  seemed  to  have  the  faculty  of  tracing  simple  figures 
such  as  squares,  circles,  and  crosses,  but  she  could  not  copy 
simple  printed  letters,  although  she  could  trace  them  fairly 
well.  When  asked  to  make  a  square  or  a  circle  after  she 
had  been  shown  a  drawing  of  one,  or  to  make  such  figures 
from  memory  she  failed  in  the  attempt. 

To-day  she  seems  to  be  able  to  match  pennies  with 
considerable  accuracy.  If  I  put  down  three  pennies  and 
ask  her  to  put  down  an  equal  number,  she  does  so.  She 
also  matches  heads  and  tails  very  well.  She  cannot  call 
the  notation  of  money. 

She  does  not  appear  to  be  so  well  to-day  as  heretofore. 
She  is  emotional  and  several  times  is  about  to  cry,  and 
when  starting  to  cry  she  says  something  about  children. 

Examination,  November  ^.th,  1896. 

What  is  your  name  ?     Lucy. 

Is  that  all  of  your  name  ?     Lucy  Reilly. 

Is  it  not  Lucy  Black?     No,  ma'am. 

Is  it  not  Lucy  Brown?     Lucy  Brown. 

What  is  your  name  ?  Lucy  Reilly,  I  told  you  (indig- 
nantly). 

You  said  it  was  Lucy  Brown  ?  Me  (in  tone  of  aston- 
ishment) ?  No,  sir. 

Well,  is  it  not  Lucy  Brown  ?     Yes,  I  told  you  it  was. 

How  can  you  have  two  names,  Lucy  Brown  and  Lucy 
Reilly?  m'm'w  son. 

What  about  your  son  ?     He's  dead,  he  is. 

Well,  what  about  him  ?     Nothing  at  all. 

Then  what  did  you  mention  him  for?  Oh,  I  don't 
know. 

Did  you  ever  go  to  school  ?     Not  much ;  no,  sir. 

Why  not  ?  Don't  want ;  the  doctor  told  me,  washing 
all  the  time,  my  mother. 


236  The  Faculty  of  Speech. 

Can  you  read  ?     No,  sir.     Why  not  ?     Cause  I  could. 

How  old  are  you?  Ma  answere,  mo  amte  got  my 
age. 

How  old  do  you  think  you  are  ?     I  can't  tell. 

Are  you  a  hundred  ?     Oh,  no. 

Are  you  more  than  one  hundred  ?     Yes,  sir. 

Less  than  one  hundred  ?  I  don't  know.  (This  is  rather 
characteristic.)  She  apparently  appreciated  the  ridiculous- 
ness of  asking  her  if  she  were  upward  of  one  hundred,  still 
in  the  very  next  breath  she  said  that  she  was.  Then  she 
denied  it,  and  if  her  questioner  looked  astonished  or  in- 
credulous she  became  embarrassed  or  indignant.  One  is 
almost  sure  that  she  does  not  understand  the  question,  but 
she  assures  him  that  she  does.  Then  the  next  moment 
she  answers  a  question  not  only  properly  but  very  quickly ; 
for  instance : 

How  do  you  feel  to-day?  First  rate,  only  I  want  to  go 
home,  that's  all. 

Where  do  you  live?  I,  I'v,  I  told,  I  can't  tell  you,  I 
can't  tell  you  now,  but  I  know  the  name  of  the  street  all 
the  same. 

Tell  me  how  your  sickness  came  on. 

She  hesitates,  and  after  a  time,  during  which  she  seems 
to  be  getting  ready  to  talk,  she  begins  :  "  One  day — I  had 
— the  morning — I  was  on  street — swashing — one  day — I 
was — my  mouth — come — she  said  I  was  so  tizzy — I,  I,  I, 
—morning — I  forget  the  rest." 

All  this  is  told  in  a  long  drawn-out  way,  as  if  she  were 
telling  a  story  that  she  had  memorized. 

Test  for  Recognition  of  Money. 

(Handful  of  change,  eighty-one  cents.)  How  much? 
Fifty  cents.  (This  after  she  picks  the  coins  up  in  suc- 
cession, looks  at  them,  and  feels  them  with  great  de- 


Sensory  Aphasia.  237 

liberation).  Then  I  ask  again,  How  much?  She  hesi- 
tates. 

(Holding  up  twenty-five-cent  piece)  How  much? 
Three,  I  told  you. 

One  cent  ?     Three  cents. 

Ten?  Three  cents,  f,  f,  f,  f  (as  if  endeavoring  to 
say  fifty  or  five). 

Fifty?     M'o,  five,  no. 

Is  it  fifteen  ?     No. 

Is  it  ten  ?     Yes  (correct). 

Examination,  November  2$th. 

How  many  fingers  are  held  up?  One,  two,  three,  four, 
five,  six,  seven,  seven,  five,  seven,  five,  five  fingers  (lat- 
ter correct). 

(Holding  up  seven  fingers)  How  many?  Nine.  (It 
seems  that  she  cannot  tell  without  reckoning  on  her  own 
fingers,  and  then  not  correctly.) 

I  hold  up  five  fingers,  and  she  counts  them  slowly  and 
correctly. 

I  hold  up  ten  fingers,  and  she  responds  "nine." 

Ten,  wasn't  it  ?     Yes,  sis. 

She  is  now  given  a  roll  of  money  and  asked  to  count  it. 
She  turns  it  over,  separates  the  individual  bills,  then  pays 
no  attention  to  it  until  told  to  go  on  with  it  again.  There 
are  fourteen  dollars  in  the  roll.  She  counts  the  four  one- 
dollar  bills,  but  hesitates  when  she  comes  to  the  ten-dollar 
bill,  and  then  says :  Dollars,  dollars,  you  know  what  I 
mean. 

Show  me  with  your  fingers  how  many  dollars  that  bill 
stands  for?  She  makes  no  reply.  She  is  either  unable 
to  respond  or  she  does  not  comprehend  the  question,  and 
emotionally  there  is  no  evidence  that  she  does  understand. 

It  is  a  twenty-dollar  bill,  isn't  it?     Yes,  yes,  sir. 


238  The  Faculty  of  Speech. 

It  is  a  twenty-dollar  bill  ?     No,  sir. 

Well,  you  said  it  was  a  twenty-dollar  bill  ?  (Exclama- 
tion of  indignation  and  surprise.)  I  did?  No,  sor;  no, 
sir;  (mumbling)  yes,  sir;  no,  sir. 

Did  you  ever  go  to  school  ?  Once  in  a  while. 
Couldn't ;  working  all  the  time.  Well,  when  I  was  a  girl, 
playing  all  the  time.  Yes,  sir,  working. 

A  cat  walks  into  the  room,  and  I  ask  her  to  tell  me 
what  it  is.  She  replies  quickly  and  promptly,  That  is  a 
book. 

It  is  a  little  book?     Oh,  no,  sir.      Or,  no.     No. 

Well,  you  said  it  was  a  book.  (Indignation)  I  ?  Oh, 
no,  sir. 

Well,  what  is  it?     (Hesitatingly)  a  child.     A  little  girl. 

What  color  is  it  ?     I  can't  call  it. 

I  kept  urging  her  to  name  it,  and  finally  she  burst  out, 
"It's  a  little  cat." 

Is  it  the  same  color  as  that  (holding  up  brown  paper)  ? 
A.  No,  sir.  As  you  ?  Yes,  sir. 

She  not  infrequently  uses  "  Yes,  sir,"  for  "  No,  sir,"  and 
vice  versa,  and  sometimes  there  is  a  repetition  of  words — 
"  intoxication"  by  a  word. 

What's  that  (pointing  to  bird  in  cage)  ?     Bird. 

What  kind  of  bird  ?     I  know  but  can't  tell. 

It's  a  robin,  isn't  it?      Yes,  sir. 

It's  a  canary  bird  ?  Yes,  sir.  I  knew  it  was.  A 
robin.  What  is  it  ? 

A  robin?  No,  I  tell  you  it's  a  canary.  Yes,  sir;  I 
said  it  was  a  robin  (indignant  tone  of  voice). 

(Pointing  to  a  pair  of  shoes.)  What  are  those  ?  Ladies' 
shoes. 

(Pointing  to  an  artificial  orange.)      Ladies'  shoes. 

(Pointing  to  a  mirror?)     Ladies  (hesitates). 

(Pointing  to  a  purse.)     Can't  call  it. 


Sensory  Aphasia.  239 

(Pointing  to  a  book.)  Bo',  bo',  bo',  I  can't  call  it,  I 
can't.  (Stops  abruptly.) 

Lucy,  tell  me  again  about  your  sickness?  One  day 
wa'  was  washing,  and  all  I  tell  you  that,  I  don't  know — I 
tell  you,  but — was,  s  s  washing,  com — par — my  daughter, 
the  girl — me,  and  I  should — I  can't,  I  can't,  and  then 
the  girl,  washing,  oh,  o-h,  the  boy — other,  some  stuff,  and 
I  look,  that's  all,  got  me — I  said  it,  see?  Well,  tant,  I 
can't  tan — o-h,  I  can't  tell  that. 

Tell  me  what  you  did  yesterday.  Warden,  on — I — 
sway — all — looking — warden — names — fighting,  fighting, 
fighting,  I'll  go  home  anyhow.  Se  doctor — names — (it  is 
thought  that  the  patient  is  endeavoring  to  say  that  some 
of  the  other  patients  in  the  ward  taunt  and  tantalize  her, 
call  her  nigger,  etc. ,  and  when  she  is  asked  if  this  is  so 
she  responds  promptly  that  it  is.) 

I  ask  her  to  repeat  the  following  sentence,  "  I  am  de- 
lighted to  make  your  acquaintance."  Way,  m',  me,  me, 
m,  once,  me  (continued  to  get  more  monotonous  and 
lower). 

Lucy,  what  day  of  the  week  will  to-morrow  be?  Pure, 
fure,  not  Friday,  I  can't  call  it. 

Friday?      No,  sir. 

Saturday?  Yes,  sir.  (After  a  little  bit,  when  her 
interlocutor  makes  no  reply,  she  promptly  says,  "  No,  sir.) 
Thus  she  is  absolutely  unable  to  repeat.  She  is  also 
completely  unable  to  read  words  and  letters,  and  I  be- 
lieve unable  to  read  figures,  although  I  have  never  been 
able  to  convince  myself  of  the  latter.  Sometimes  she 
apparently  recognizes  the  figures  on  a  banknote.  Cer- 
tain it  is  that  she  cannot  read  figures  on  a  test  card.  She 
is  unable  to  write  a  letter  spontaneously  or  from  dictation, 
and  she  is  unable  to  copy,  except  the  simplest  lines.  She 
is,  however,  able  to  trace. 


240  The  Faculty  of  Speech. 

It  is  now  for  the  first  time  made  quite  certain  that 
she  has  typical  right-side  homonymous  hemianopsia.  This 
was  thought  to  be  the  case  after  the  first  examination, 
but  the  paraphasic  answers  on  the  part  of  the  patient 
and  the  difficulty  in  making  her  comprehend  what  was  de- 
sired of  her  when  objects  were  brought  into  the  visual 
field,  made  the  test  very  uncertain.  To-day  objects  thrust 
toward  the  right  sides  of  both  eyes,  as  if  they  were  going 
directly  into  the  eye,  do  not  cause  the  slightest  blink- 
ing. A  candle  brought  toward  on  the  right  side  is  not 
perceived  until  it  gets  beyond  the  mid  line. 

When  a  summary  is  made  of  the  results  of  repeated  ex- 
aminations of  the  speech  defects  of  this  patient,  we  find 
that  the  most  striking  defects  of  spontaneous  speech  are 
amnesia  of  words,  particularly  of  nouns,  and  paraphasia. 
The  patient  can  usually  tell  her  name,  but  she  cannot  tell 
the  names  of  members  of  her  family  or  her  residence. 
In  fact,  even  to-day  we  do  not  know  where  she  lived  or 
the  names  of  any  of  her  friends.  The  articulatory  images 
seem  to  be  preserved.  If  she  can  call  up  what  she  wishes 
to  say,  there  is  no  difficulty  in  saying  it.  It  is  impossible 
for  her  to  repeat  the  simplest  sentence  after  me.  This  is 
well  illustrated  by  her  effort  to  repeat  the  conventional 
phrase,  "  I  am  glad  to  make  your  acquaintance."  All  that 
she  produces  is  an  unintelligible  mixture  of  sounds  consti- 
tuting gibberish.  There  is  relative  preservation  of  the 
melody  of  some  songs  with  inability  to  use  the  proper 
words.  She  can  sing  the  airs  of  hymns  and  popular  tunes, 
but  she  cannot  get  the  words  in  properly.  There  is  in- 
ability to  read  aloud  or  to  herself.  She  cannot  write  spon- 
taneously or  from  dictation,  and  there  is  very  great  diffi- 


Sensory  Aphasia.  241 

culty  in  copying.  In  copying  simple  geometric  figures,  if 
the  copy  is  removed  for  a  moment  she  cannot  go  on  with 
the  delineation.  There  is  word  blindness,  a  loss  of  the 
comprehension  of  written  and  printed  words.  She  is  still 
capable  of  distinguishing  one  object  from  another,  one 
color  from  another ;  and  she  can  match  pennies  with  some 
certainty.  Figures  on  a  banknote  are  recognized  but  not 
mentioned.  During  one  test  she  seemed  to  have  little  or 
no  notion  of  the  difference  between  a  letter  and  a  word, 
and  in  looking  at  a  printed  page  she  could  not  point  out 
single  letters  as  different  units  from  the  individual  groups 
of  letters  constituting  single  words.  There  is  right 
lateral  homonymous  hemianopsia.  There  is  a  slight 
degree  of  word  deafness,  which  becomes  more  apparent 
the  longer  the  case  is  studied.  This  word  deafness  does 
not  seem  to  me  to  be  due  so  much  to  a  destruction  as  to 
a  functional  degradation  of  the  auditory  word  centre.  This 
functional  degradation  is  the  most  patent  cause  of  her  am- 
nesia. The  amnesia  verbalis  which  she  has,  i.e.,  of  per- 
sons, places,  and  things,  is  the  usual  kind  of  amnesia  as- 
sociated with  slight  disorder  of  the  auditory  area.  The 
symptoms  which  she  presents  are  characteristic  of  sensory 
aphasia,  and  I  believe  it  to  be  a  case  of  sensory  aphasia 
in  which  lesion  of  the  visual  centre  and  the  subadja- 
cent  white  substance  is  responsible  for  the  leading  speech 
disturbances.  Her  capacity  to  speak  and  her  vocabulary 
vary  from  day  to  day,  and  vary  considerably  with  her  dis- 
position and  general  tone.  She  has  shown  herself  able  to 
articulate  with  distinctness  at  times  words  presented  to 
her  consciousness  by  voluntary  recall  of  past  impressions, 
by  auditory  impressions,  and  by  association ;  i.e.,  those  sug- 
16 


242  The  Faculty  of  Speech. 

gested  to  her  mind  by  an  appropriate  question.  She  fre- 
quently says,  "  I  can't  tell,"  and  oftentimes  in  such  situa- 
tions she  manifests  the  state  that  is  best  termed  amnesia 
verbalis.  This  amnesia  is  most  marked  for  proper  names 
and  nouns,  and  very  slight  for  verbs,  adjectives,  and  pro- 
nouns. It  is  not  easy  to  decide  whether  this  be  due  to 
conceptual,  to  kinaesthetic,  or  to  auditory  amnesia,  and  no 
tests  so  far  have  positively  settled  which  one  of  these 
important  elements  is  most  disturbed,  but  it  is  very  prob- 
able that  the  amnesia  is  predominantly  auditory.  On  the 
other  hand  she  at  times  indicates  that  the  word  is  just  on 
the  tip  of  her  tongue.  It  appears  as  though  the  word  were 
mentally  formed.  She  gives  every  indication  of  know- 
ing what  she  wants  to  say  and  of  having  the  feeling  of 
making  the  proper  innervations ;  but  the  wrong  word  comes 
out.  In  other  words  there  is  paraphasia.  This  wrong 
word  frequently  presents  interesting  relationships  with  the 
correct  word ;  if  she  is  asked  to  say  B,  she  may  say  C  in- 
stead. On  one  occasion  when  asked  to  say  X,  she  called 
out  I.  •  Here  there  was  a  double  relationship,  first  to  the 
contiguous  letter  Y,  and  then  to  the  similarly  sounding  let- 
ter I.  Many  contrast  relationships  manifest  themselves, 
such  as  saying  "yes"  when  she  means  "no;"  "mam" 
instead  of  "sir."  The  wrong  word  was  also  frequently 
associated  by  similarity  of  sounds  with  the  proper  one. 
The  influence  of  words  just  heard,  or  just  thought  of, 
also  manifests  itself  occasionally,  simulating  an  enforced 
echolalia.  There  are  many  instances,  moreover,  which 
suggest  that  the  right  word  is  just  about  to  be  spoken 
after  a  number  of  struggles,  without  any  result;  "wed"  has 
been  enunciated  for  "  red,"  and  through  a  series  of  approxi- 


Sensory  Aphasia.  243 

mations  of  this  sort,  the  patient  has  frequently  been  able 
to  arrive  at  the  proper  word  or  words. 

She  seems  to  have  hypersesthesia  to  tone  vibrations, 
and  they  appear  to  produce  a  disagreeable  tickling  sensa- 
tion in  the  ears.  This  is  mentioned  because  it  has  been 
associated  by  Freund  and  others  with  verbal  perceptual 
deafness,  without  general  acoustic  deafness.  The  pa- 
tient, despite  this  intelligent  hesitation  in  responding 
to  questions,  shows  at  times  a  faulty  perception  of  the 
significance  of  the  words  of  others.  I  say  to  her, 
"  You  said  yesterday  that  you  had  three  children,"  and 
she  will  say,  "  Yes,  three. "  I  say,  "  What  were  they, 
"two  boys  and  a  girl?"  She  will  say,  "No,  two  boys." 
I  then  say,  "  You  have  three  children,  both  of  whom  are 
boys?"  She  will  say,  "Yes,"  even  repeating  the  state- 
ment after  me.  If  I  then  say,  '"  You  do  not  mean  three 
children,  you  mean  two,"  she  will  say,  "Yes,  two."  In 
repeating  words  and  letters  her  greatest  difficulty  seems 
to  be  on  the  articulatr/y  side.  Nevertheless,  I  feel  cer- 
tain that  there  is  some  perceptual  word  deafness,  but  it  is 
the  slightest  of  her  deficiencies.  She  seems  to  call  up 
with  a  great  degree  of  certainty  the  use  and  significance 
of  objects,  and  even  their  names.  At  times,  however, 
she  shows  marked  deficiencies  amounting  almost  to  com- 
plete perceptual  blindness.  I  have  seen  her  overlook  an 
object  that  was  held  in  the  hand,  which  I  named  with  dis- 
tinctness and  with  which  she  had  shown  herself  quite 
familiar.  She  tried  to  strike  a  match  on  the  inside  of  a 
box,  although  she  had  just  shown  that  she  understood  the 
significance  of  a  match  and  understood  what  striking  it 
meant,  and  it  was  not  until  I  had  told  her  that  she  should 


244  '-The  Faculty  of  Speech. 

strike  it  on  the  outside  and  move  the  box  about  a  little 
that  she  seemed  to  perceive  the  side  of  the  box,  felt  of 
it,  and  then  ignited  the  match. 

The  mental  power  that  seems  most  persistently  deficient 
is  the  ability  to  grasp  ideas  of  number.  If  I  say,  "  Match 
that  penny,"  she  will  put  the  penny  down,  correctly  match- 
ing it.  If  I  say,  "  Put  down  as  many  pennies  as  I  do," 
she  is  utterly  at  sea.  She  seems  to  have  no  notion  of 
number.  This  is  manifest  also  in  regard  to  relative  ages. 
She  seemed  only  to  be  sure  that  her  mother  was  older  than 
herself.  A  fairly  simple  task  she  performs  with  ease ;  but 
even  a  small  complication  throws  her  off  the  track.  She 
matches  one  penny  at  a  time  with  ease.  Put  down  three 
pennies  and  ask  her  to  match  them  with  an  equal  number, 
even  though  the  pennies  are  widely  separated,  she  will  put 
down  all  the  coins  in  her  hand,  at  the  same  time  making 
no  attempt  to  match  them ;  or,  if  she  does,  failing  signally 
to  do  so.  The  case  seems  to  present  some  symptoms  of 
restriction  of  consciousness  and  of  detachment  of  con- 
sciousness, such  as  are  met  with  in  cases  of  hysteria. 
Then  again  she  shows,  but  only  very  occasionally,  a  blank 
stupidity,  absent-mindedness,  or  mental  vacuity  and  conse- 
quent confusion. 

Auditory  ApJiasia.      Verbal  Deafness.      Word  Deafness. 

In  discussing  the  localization  of  the  various  sensory  and 
motor  elements  involved  in  the  faculty  of  speech,  we  dis- 
tinguish three  distinct  speech  centres :  the  articulatory, 
the  auditory,  and  the  visual  centres.  Strictly  speaking, 
the  latter  centres,  in  so  far  as  their  functions  concern  the 
faculty  of  speech,  are  not  sensory  areas  but  areas  of  per- 


Sensory  Aphasia.  245 

ception,  or,  better  still,  of  apperception.  The  so-called 
sensory  aphasias  do  not  present  disorders  of  sensation,  nor 
yet  of  simple  perception,  but  disorders  of  the  interpreta- 
tion or  understanding  of  certain  classes  of  perception. 
Destruction  of  these  centres  produces  conditions  in  which 
memory  significance  of  spoken  or  written  speech  is  lost. 
Though  the  sound  of  the  words  and  the  images  of  the 
words  may  be  clearly  perceived,  there  is  a  loss  of  co-ordi- 
nation which  prevents  these  simple  receptive  centres  from 
arousing  other  elements  in  adjacent  centres,  whose  activity 
is  necessary  in  order  to  awake  the  memory  impressions 
stored  there  as  the  result  of  past  experience  with  the 
spoken  and  written  symbols  of  speech. 

In  this  form  of  aphasia,  first  differentiated  by  Wernicke 
and  given  the  name  word  deafness  by  Kussmaul,  there  is 
inability  to  understand  spoken  words.  This  is  dependent 
apparently  upon  the  total  loss  of  auditory  verbal  memory 
images.  It  is  one  of  the  uncommonest  forms  of  aphasia, 
and  it  rarely  occurs  individually,  being  frequently  asso- 
ciated with  some  degree  of  visual  aphasia  or  motor  apha- 
sia. Strictly  speaking,  the  defect  is  not  word  deafness  at 
all,  for  not  only  do  such  patients  hear  spoken  words,  but 
frequently  they  show  no  diminution  in  the  intelligent  ap- 
preciation of  the  significance  of  simple,  co-ordinate,  or 
purposive  sounds. 

Such  patients,  although  word  deaf,  may  be  as  alert  as 
ever  to  the  significance  of  a  shrill  blast  of  the  whistle 
from  an  approaching  engine.  They  detect  sounds,  even 
the  slightest,  as  quickly  as  does  the  person  whose  auditory 
mechanism  is  intact,  and  they  seek  the  origin  and  the  sig- 
nificance of  such  sounds.  In  fact,  because  they  are  un- 


246  The  Faculty  of  Speech. 

able  to  interpret  spoken  words  they  are  often  apparently 
more  keenly  alive  to  sounds.  It  is  true  that  an  aphasic 
patient  may  also  lose  the  significance  of  differentiated  or 
purposive  sounds  but  such  an  occurrence  would  needs  be 
in  a  more  pronounced  case  of  aphasia  than  that  which  is 
typified  by  the  term  auditory  aphasia.  Such  sounds  are 
not  usually  complex  and  highly  differentiated,  therefore  loss 
of  the  capacity  to  interpret  their  significance  is  rare. 

There  are  as  many  kinds  of  auditory  aphasia  as  there 
are  varieties  of  interpretation  put  upon  symbolic  sounds 
by  our  consciousness.  The  seat  of  lesion  which  causes 
auditory  aphasia  has  already  been  pointed  out  to  be  the 
cortex  of  the  middle  and  posterior  portions  of  the  first 
temporal  convolution,  extending  over  into  the  second  tem- 
poral and  upward  into  the  supramarginal  convolution, 
where  it  impinges  upon  the  cortical  area  for  visual  verbal 
images.  Lichtheim1  has  reported  a  case  of  so-called  subcor- 
tical  auditory  aphasia  in  which  there  was  word  deafness 
with  no  disorder  of  speech.  The  lesion  was  thought  to  be 
of  the  auditory  projection  system,  in  the  white  substance 
within  the  left  cerebral  hemisphere.  Wernicke  and  his 
pupil  Freund  *  report  cases  of  extracortical  peripheral  le- 
sion, located  by  them  in  the  labyrinth,  which  manifested 
symptoms  of  word  deafness,  very  similar  to  those  reported 
by  Lichtheim  and  others,  as  due  to  subcortical  and  trans- 
cortical  aphasia.  It  would  appear  that  pseudo-aphasia 
symptoms,  which  must  be  very  carefully  distinguished 
from  those  of  true  aphasia,  may  be  due  to  actual  lesion  or 
to  functional  defect  in  the  sense  organ  or  in  part  of  the 
subcortical  receptive  tract. 

1  Loc.  fit.  9  Loc.  fit. 


Sensory  Aphasia.  247 

The  symptoms  of  auditory  aphasia  are  subjective  and 
objective.      If  the  aphasia  is  limited  to  simple  word  deaf- 
ness, the  patient  hears  the  voice  in  which  words  are  spoken, 
but    the  words  convey  no   idea    to  him    and  he  has    no 
more  comprehension  *what  they  mean  than  if  they  were 
spoken  in  a  tongue  which    he  never  before    had   heard. 
He,  however,  recognizes  the  significance  of  other  sounds, 
unless  it  be  that  the  memory  pictures  for  such  sounds  are 
also  lost.      Naturally  there  are  different  degrees  of  word 
deafness,  depending  upon  the  extent  of  the  lesion  or  the 
destruction  of  the  auditory  area.      In  some  cases  the  ex- 
tent is  so  great  that  the  sound  of  the  voice  which  speaks 
them  is  simply  perceived  as  a  sound,  and  such  patients  do 
not  recognize  the  sound  of  their  own  name.     In  other  in- 
stances they  recognize  the  sounds  of  their  own  names  and 
possibly  the  names  of  other  members  of  their  family,  their 
places  of  residence,  business,  etc.,  words  that  have  for  them 
a  much  wider  significance,  and  are  more  deeply  imprinted 
in  their  memories  than  is  the  ordinary  concrete  word.     In 
other  cases  the  limitation  of  the  lesion  in  the  auditory  area 
allows  the  patient  to  comprehend  that  he  is  being  spoken 
to,  and  possibly  to  understand  a  word  here  and  there.      It 
is  often  very  difficult  when  the  patient  gathers  the  sig- 
nificance  of  a  single  word  to  say  just  how  complete  the 
auditory  deafness  is,  unless  the  physician  be  very  careful 
in  controlling  suggestive  gestures  and  facial  expressions, 
for  some  patients  quickly  interpret  in  part  the  significance 
of  what  is   spoken  and  guess  the  rest.      If  this  form  of 
aphasia  exists  for  a  long  time,  the  patient  may  acquire  con- 
siderable skill  in  lip  reading. 

In  the  milder  forms  of  word  deafness  it  is  often  neces- 


248  The  Faculty  of  Speech. 

sary,  in  order  to  estimate  correctly  the  degree  of  word 
deafness,  to  test  trje  patient  carefully  and  repeatedly. 
For  instance,  if  the  patient  is  asked  to  protrude  the  tongue 
and  he  does  so ;  to  extend  the  right  hand  and  he  obeys,  it 
might  lead  one  far  astray  if  he  were"  to  make  a  note,  "  The 
patient  has  not  lost  the  comprehension  of  spoken  words, 
for  he  obeys  requests."  Patients  with  word  deafness  are 
often  keenly  alive  to  their  infirmity,  in  fact  morbidly  so, 
and  they  strive  to  conceal  it  by  adopting  any  ruse  that 
occurs  to  them.  As  protruding  the  tongue,  extending  the 
hand,  etc.,  are  customary  accompaniments  of  a  doctor's 
visit,  they  guess  the  meaning  of  questions  which  convey 
no  ideas  to  them,  and  sometimes  the  responses  are  perti- 
nent, either  by  accident  or  clever  gesture  reading.  In 
those  cases  in  which  the  word  deafness  is  slight,  the  pa- 
tient understands  one  or  two  words  of  a  question,  and 
pieces  it  out  in  his  own  mind  accordingly.  The  simula- 
tion can  be  easily  exposed  by  changing  the  sense  of  the 
question,  while  employing  practically  the  same  words  or  a 
number  of  the  same  words.  It  is  then  apparent  that  the 
patient  does  not  recognize  the  different  questions,  for  he 
answers  as  before. 

The  concomitant  accompaniments  of  word  deafness,  in- 
ability to  write  from  dictation,  defective  comprehension 
of  what  is  read,  imperfect  writing,  paragraphia,  etc.,  may 
be  disposed  of  very  quickly.  Inability  to  write  from  dic- 
tation, which  a  patient  with  auditory  aphasia  presents, 
needs  no  explanation.  If  the  sound  of  the  words  do  not 
revive  the  memorial  significance  of  these  words  in  the 
auditory  centre,  no  impulses  inciting  the  visual  centre  to 
visualize  the  word  proceed  from  the  auditory  centre. 


Sensory  Aphasia.  249 

Internal  reading  is  disordered,  because  the  primarily 
excited  visual  word  centre,  in  transmitting  the  impulses 
to  the  auditory  area,  finds  the  latter  disordered,  and  there' 
is  in  consequence  defective  revival  of  corresponding  word 
memories  and  lack  of  comprehension  of  what  is  read. 
The  paragraphia  is  an  expression  of  the  disorder  of  inter- 
nal language,  which  is  always  present  in  true  auditory 
aphasia. 

A  patient  with  word  deafness,  having  a  lesion  that  cuts 
him  off  from  the  significance  of  all  that  is  said  to  him  is 
practically  rendered  deaf.  And  as  the  catastrophe  comes 
suddenly,  after  he  has  for  years  been  accustomed  to  the 
delights  of  auditory  sensations,  he  is  naturally  very  much 
changed  in  manner,  in  appearance,  and  in  demeanor.  He 
is  quiet  and  observant ;  his  glance  betrays  suspicion  or 
fear,  and  his  demeanor  is  often  one  of  trouble  and  unrest. 
This  change  in  demeanor  and  manner,  combined  with  the 
paraphasia  which  is  often  strikingly  manifest,  the  inability 
to  repeat  from  dictation,  and  the  profound  diminution, 
even  to  complete  absence,  of  spontaneous  speech,  have 
often  led  physicians  and  laymen  alike  to  look  upon  these 
unfortunate  patients  as  insane.  It  need  scarcely  be  said 
that  such  an  implication  is  unjust. 

As  has  already  been  said,  word  deafness  rarely,  if  ever, 
exists  alone.  It  is  often  associated  with  cortical  mo- 
tor aphasia,  and  frequently,  on  account  of  the  proximity 
of  the  auditory  area  to  the  visual  area,  with  some  degree  of 
word  blindness.  Wernicke  and  Lichtheim  claim  to  have 
seen  cases  in  which  there  were  absolutely  no  defects  of 
articulate  speech.  If  the  first  of  these  two  conditions  ex- 
ists, the  patient  is  unable  to  communicate  thoughts  in 


250  The  Faculty  of  Speech. 

writing  and  is  dyslexic,  while  if  the  last  be  present  he 
is  word  blind  as  well. 

Examination  of  patients  with  word  deafness  reveals  dif- 
ferent objective  conditions  dependent  upon  the  degree  and 
completeness  of  the  word  deafness.  Even  though  the 
patient  does  not  grasp  the  question  that  is  addressed  to 
him,  he  will  endeavor  to  give  answer,  but  the  answer  has 
no  pertinency  to  the  interrogation ;  in  the  first  place  be- 
cause the  patient  does  not  understand  the  question,  and  in 
the  second  place  because  emissive  speech  is  dependent 
upon  the  integrity  of  the  auditory  centre,  that  is,  upon  the 
revival  of  auditory  memories  and  their  transmission  to  the 
articulatory  kinaesthetic  centre.  On  account  of  the  fact 
that  the  centre  for  articulatory  memories  is  guided  and 
correlated  in  action  by  the  auditory  centre,  disease  of 
the  latter  causes  not  only  amnesia  of  words,  but  misuse  of 
words,  a  condition  to  which  the  name  paraphasia  is  given. 
I  have  said  before  that  a  patient  in  whom  the  primary  re- 
vival of  words  has  been  through  the  auditory  centre  will 
be  more  incapacitated  by  a  lesion  that  interferes  with  his 
auditory  centre  than  will  one  who  relies  in  part  or  largely 
on  the  revival  of  visual  memories  of  words,  or  for  the  re- 
inforcement of  the  memory  of  words  by  visual  images. 
Such  individuals  are  rare  compared  with  those  who  revive 
words  through  auditory  memories,  but  nevertheless  they  ex- 
ist. An  illiterate  man  who  gets  word  deafness  becomes  al- 
most speechless,  because  the  illiterate  man  is  then  deprived 
of  his  only  mode  of  recalling  words  to  mind.  According 
to  Hughlings  Jackson,  Ballet,  Strieker,  and  others,  words 
may  be  revived  as  motor  processes,  i.e.,  by  stimulation  of 
the  centre  of  articulation  (which  they  consider  motor).  It 


Sensory  Aphasia.  251 

is  perhaps  unnecessary  to  say  here  that  the  writer  does  not 
admit  this,  for  it  is  one  of  the  fundamental  ideas  in  the 
conception  of  aphasia  that  he  has  put  forth  that  Broca's 
area  is  not  motor  but  sensory,  as  has  been  contended  by 
Bastian  for  more  than  a  quarter  of  a  century.  Moreover, 
in  another  place  it  has  been  pointed  out  that,  developmen- 
tally,  in  the  child  the  articulatory  power  is  conditioned  by 
audition.  If  the  centre  in  which  are  stored  the  articulo- 
kinaesthetic  memories  of  words — that  is,  Broca's  centre — 
is  not  affected,  articulation  of  words  revived  in  thought  by 
visual  impressions  may  be  but  little  impaired.  This  is 
especially  noticeable  in  response  to  questions  the  signifi- 
cance of  which  the  patient  gets  through  the  visual  areas ; 
that  is,  questions  addressed  to  him  by  writing  and  by  pan- 
tomime. But  in  such  replies  the  words  may  be  transposed, 
because  the  patient  is  not  in  possession  of  the  faculty  to 
know  whether  or  not  they  have  the  proper  sequence,  for 
he  can  hear  his  own  words  no  better  than  he  can  those  of 
others,  and,  the  auditory  centre  being  destroyed,  the  artic- 
ulatory centre  is  deprived  of  the  directing  control  which 
the  former  exercises  over  the  latter.  It  is  very  necessary 
that  this  statement  should  be  as  lucid  as  possible.  If 
when  one  is  speaking  aloud  a  word  is  misplaced  or  a  word 
is  not  used  in  its  proper  sense,  if  there  be  made  what  is 
called  a  lapsus  lingua,  the  auditory  area,  which  is  keenly 
alive  to  the  slightest  misuse  of  words,  quickly  detects  the 
error  and  communicates  it  to  the  intelligence  or  carries  it 
into  consciousness.  This  in  turn  calls  up  the  articulatory 
image  of  the  proper  term,  which  is  then  articulated.  The 
sound  of  every  articulated  word  acts  as  a  stimulus  to  the 
auditory  centre  for  the  next.  If  the  auditory  centre  has 


252  The  Faculty  of  SpeecJi. 

been  destroyed  there  is  no  such  leader  in  the  memorial 
order  of  words,  and  the  frequent  occurrence  of  lapsus  lin- 
guae constitutes  paraphasia.  The  patient  is  usually  not 
cognizant  of  the  mistakes  that  he  makes  in  speaking, 
though  sometimes  when  he  is  he  treats  them  lightly  and 
essays  not  to  notice  them,  or  he  is  loath  to  express  him- 
self in  words  at  all,  providing  he  be  in  no  way  demented. 
Usually,  however,  the  patient  with  partial  auditory  apha- 
sia is  loquacious,  the  logorrhoea  being  devoid  of  sense  or 
pertinency.  Occasionally  one  encounters  a  patient  with 
word  deafness  who  prefers  to  answer  questions  in  writing, 
because  the  intactness  of  the  visual  memories  of  words 
enables  him  to  control  his  output.  In  a  similar  way  the 
auditory  centre  guides  the  action  of  the  articulatory  centre 
in  the  employment  of  internal  language.  In  other  words, 
I  do  not  believe  that  the  motor  centre  of  speech  ever  be- 
comes independent  of  the  sensory  centre  which  presided 
over  its  education,  as  is  claimed  by  Bernard  in  his  exten- 
sion of  Charcot's  teaching. 

If  the  visual  area  is  coincidently  diseased  and  the  pa- 
tient has  right-side  hemiplegia  as  well,  such  a  patient  will 
be,  objectively,  as  one  without  a  mind.  The  important  re- 
ceptive avenues  of  speech  are  closed  to  him  and  the  emis- 
sive, likewise.  He  may  be  able  to  make  known  some  of 
his  thoughts  or  wants  by  means  of  pantomime,  but  just 
how  much  it  is  very  difficult  to  say,  except  by  the  study  of 
each  individual  case.  As  an  instance  of  a  case  of  this  kind 
I  may  cite  the  following,  which  I  saw  with  Dr.  H.  P. 
Hirsch : 

A.   M ,  German,   fifty-nine  years  old,  married;    by 

occupation  a  merchant.     His  wife  has  had  four    miscar- 


Sensory  Apkasia.  253 

riages  and  has  borne  one  full-term  child,  which  has  since 
died.  The  patient,  who  had  been  a  temperate,  well-pre- 
served man,  of  a  kind  and  lovable  disposition,  was  in  ex- 
cellent health  until  about  three  years  before  the  onset  of  his 
present  illness,  when  he  had  an  attack  of  rheumatic  sciatica. 
Since  then  he  has  had  recurring  attacks  of  "  rheumatics" 
in  the  arms  and  legs.  About  two  years  after  the  attack  of 
sciatica  he  had  a  mild  attack  of  endocarditis.  During  the 
year  preceding  the  present  illness  his  entire  disposition 
and  temperament  underwent  a  change.  He  became  iras- 
cible, irritable,  worried  over  trifles,  and  got  fatigued  more 
easily  than  formerly.  He  never  complained  of  headache, 
nor  were  there  symptoms  that  led  to  an  examination  of 
the  urine.  Attacks  of  the  blues  came  oftener  and  stayed 
longer. 

On  the  afternoon  of  the  2 1  st  of  November  the  patient 
came  home  from  business,  apparently  in  his  usual  health. 
He  sat  in  an  easy  chair  and  read  a  paper.  Suddenly  with- 
out warning  his  wife  noticed  his  arms  drop,  his  eyes  roll 
up,  his  respirations  become  dyspnoeic.  She  applied  re- 
storatives and  in  about  five  minutes,  he  recovered  con- 
sciousness, asked  his  wife  what  she  was  troubled  about, 
did  not  seem  to  recognize  that  anything  had  befallen  him, 
averred  that  he  was  all  right,  and  did  not  want  a  phy- 
sician. If  he  appreciated  that  he  had  had  an  attack  of 
unconsciousness  he  did  not  say  anything  about  it,  and 
when  dinner  time  came  he  went  to  the  table  as  usual  and 
partook  of  the  meal.  It  was  noticed  by  the  members  of 
the  family  that  he  did  not  use  the  right  hand  so  much  as 
usual,  and  he  said  that  it  felt  somewhat  stiff  and  heavy. 
Before  retiring  he  took  a  hot  bath,  and  on  getting  out  of 
the  tub  he  had  another  syncopal  attack  of  very  short  dura- 
tion. He  passed  a  restless  night,  and  in  the  morning  on 
arising  he  found  that  his  right  hand  was  very  stiff,  un- 


254  The  Faculty  of  Speech. 

wieldy,  and  lame.  He  seemed  to  be  in  other  respects 
quite  well.  There  were  no  noticeable  change  of  facial  ex- 
pression, no  hesitation  of  speech,  and  no  difficulty  of  getting 
about.  On  the  afternoon  of  the  22d,  Dr.  Hirsch,  a  friend 
but  not  heretofore  his  physician,  was  sent  for.  He  noted 
that  the  pulse  was  rapid  and  hard,  the  face  flushed  and 
anxious,  and  the  patient  evidently  in  a  very  anxious  state. 
Examination  showed  a  paralysis  of  the  right  arm  which, 
although  not  complete,  prevented  the  patient  from  using 
the  arm  except  slightly.  There  was  no  involvement  of 
the  face  or  of  the  right  leg.  There  were  no  sensory  dis- 
turbances. The  patient  seemed  to  be  in  fullest  possession 
of  his  faculties,  talked  distinctly,  and  explained  rationally 
to  the  physician  why  he  had  been  selected  as  the  medical 
adviser ;  told  of  his  symptoms,  showed  that  he  was  able  to 
read  understandingly,  and  in  other  ways  demonstrated  that 
he  used  words  at  their  proper  worth. 

The  physician  was  sent  for  again  about  seven  o'clock 
that  evening.  The  patient  had  become  unconscious  while 
in  the  bathroom.  He  remained  profoundly  unconscious 
for  upward  of  seventy-two  hours,  during  which  time  his 
temperature  was  subnormal.  He  then  recovered  conscious- 
ness gradually.  He  was  completely  paralyzed  on  the  right 
side,  unable  to  speak,  and  apparently  unable  to  understand 
anything  that  was  said  to  him.  For  the  next  six  weeks  he 
was  completely  speechless  ;  then  he  began  to  say  the  words  . 
"  Yes"  and  "  No"  and  some  other  monosyllabic  words,. but 
he  did  not  use  them  correctly.  He  has  not  been  able  to 
understand  spoken  or  written  words  since  the  attack.  Oc- 
casionally, if  commands  are  repeated  a  number  of  times, 
such  as  "Put  out  your  tongue,"  etc.,  he  will  obey,  but 
almost  always  it  is  necessary  to  show  him  pantomimically 
what  is  meant.  After  the  second  month  his  newly  ac- 
quired, limited,  monosyllabic  vocabulary  began  to  shrink, 


Sensory  ApJiasia.  255 

and  then  he  began  to  "  babble"  and  to  echo  words  that  he 
heard.  The  babbling  became  almost  continuous  for  a  time 
and  it  was  thought  that  the  patient  was  insane.  After  a 
while  it  became  less  frequent  and  was  produced  only  in 
response  to  or  after  a  question. 

One  day,  about  six  weeks  after  the  attack,  he  suddenly 
began  to  sing  a  German  song,  which  he  had  often  sung, 
"  O  Tannenbaum,  O  Tannenbaum,  bau,  bao,  ba,  ba,  ba,  bo, " 
ending  in  a  laugh ;  and  on  a  number  of  occasions  he  es- 
sayed to  sing  when  the  piano  was  played,  but  he  never  got 
beyond  a  few  words. 

Status,  March  i6th,  1897,  nearly  four  months  after  the 
beginning  of  the  present  disease.  There  is  hemiplegia  of 
the  right  side  of  the  body,  the  right  side  of  the  face  being 
involved  only  to  a  very  slight  degree.  The  paralysis  of 
the  extremities  is  not  pronouncedly  spastic,  but  the  ten- 
don jerks  are  very  much  exaggerated.  The  heart  impulse 
is  weak,  about  ninety  times  a  minute ;  there  is  a  harsh 
systolic  murmur,  heard  with  greatest  intensity  over  the 
aortic  valve  and  the  second  sound  is  accentuated.  The 
pulse  is  small  and  feeble. 

On  being  asked  his  name  he  begins  to  whine  and  intone 
sounds  which  may  be  expressed  by  the  following  words : 
"  Nein,  nein,  na,  no,  no,  nein,  bettau,  betta,  tau,  tau,  nein, 
nein,"  etc.,  beginning  in  a  moderate  tone  and  then  get- 
ting higher  pitched,  and  ending  in  a  babble.  All  the  time 
the  musculature  of  the  face  is  in  such  a  state  that  on 
looking  at  the  patient  one  would  suppose  that  he  is 
crying,  but  in  reality  there  are  no  tears. 

"  How  old  are  you  ?"  No  response,  but  after  a  few  mo- 
ments he  begins  the  above  senseless,  articulated  babble. 

"  Are  you  ninety  years  old  ?"  Does  not  recognize  that 
he  is  being  spoken  to. 

In  fact,  test  as  long  and  as  completely  as  we  may,  it 


256  The  Faculty  of  Speech. 

is  absolutely  impossible  to  convey  any  meaning  to  him 
by  spoken  word.  He  is  alive  to  the  slightest  noise,  and 
turns  his  head  when  a  person  comes  in  the  room  or  on  the 
occasion  of  a  slight  noise  the  origin  of  which  he  does  not 
understand. 

It  is  possible  that  there  is  right  homonymous  hemi- 
anopsia.  It  was  difficult  to  get  positive  proof  of  this,  as 
it  is  in  all  cases  in  which  the  patient  cannot  understand  a 
word  that  is  spoken  to  him  and  does  not  comprehend  writ- 
ing. The  wife,  however,  suggested  its  presence  by  insist- 
ing that  when  she  approached  anything  to  his  mouth  from 
the  right  side,  such  as  in  giving  him  a  spoonful  of  medi- 
cine, or  to  wash  his  eye,  he  did  not  see  her  until  after 
she  had  got  it  immediately  in  front  of  him.  On  bringing 
the  finger  or  fist  quickly  toward  the  right  side  of  the  eye, 
the  patient  does  not  blink  or  make  any  movement  to  indi- 
cate that  he  recognizes  the  approaching  object  which  is 
seemingly  going  directly  into  his  eye.  When  the  same 
test  is  tried  on  the  other  side,  the  eye  blinks  at  once,  and 
he  even  indicates  that  he  sees  objects,  such  as  the  light  of 
a  candle  brought  into  the  visual  field  from  the  left,  but  in 
no  way  gives  heed  to  it  when  brought  into  the  visual  field 
from  the  right. 

There  is  complete  alexia.  A  letter  from  his  family, 
who  are  in  Europe,  is  given  to  him,  but  although  he  takes 
it  in  the  hand  he  does  not  recognize  a  word.  It  is  the 
same  with  print.  There  is  total  agraphia;  he  cannot 
make  a  stroke  with  the  pencil  put  in  the  left  hand.  When 
the  hand  is  made  to  grasp  it  and  the  physician's  hand 
guides  it  to  shape  a  word,  he  takes  no  interest  in  the  matter, 
apparently  not  having  the  slightest  idea  of  what  is  being 
done,  and  begins  to  say,  "  Nein,  nein,  na,  na,  bateau,"  etc. 

There  is  in  addition  to  this  some  mind  blindness,  but 
this  does  not  seem  to  be  so  pronounced  now  as  it  was  a 


. 


Sensory  Aphasia.  257 

few  weeks  before,  when  he  many  times  endeavored  to  drink 
out  of  the  urinal,  and  in  other  ways  showed  that  he  did  not 
recognize  the  uses  of  objects.  Nevertheless  the  apraxia  is 
not  complete,  for  when  given  his  eyeglasses  he  places  them 
astride  his  nose,  in  a  particularly  dexterous  and  intelligent 
way.  This,  however,  may  be  an  automatic  act. 

Voluntary  speech  is  entirely  lost,  except  the  words  that 
we  have  given,  which  he  uses  on  all  occasions.  Repeti- 
tion of  speech  is  also  lost,  but  sometimes  he  surprises  the 
examiner  and  the  family  by  echoing  what  is  said,  particu- 
larly if  it  be  said  a  number  of  times  and  in  a  loud  voice. 

For  instance,  if  one  says  "  Good  by"  or  "  Good  morning" 
a  number  of  times,  he  may  respond  like  a  parrot,  "  Good  by, 
ba,  ba,  ba,  ba,"  and  he  will  take  up  the  old  refrain,  "  Na, 
nein,  nein,  betteau,"  etc. 

In  this  way  he  occasionally  says,  "  Pfui"  (first  used  by 
his  wife,  on  one  occasion  when  he  was  about  to  drink  from 
the  urinal) ;  "  Lieb, "  after  the  question,  "  Liebst  du  mich  ? 
Hast  du  mich  lieb?"  Without  in  the  slightest  manner 
understanding  the  question  he  may  articulate  with  con- 
siderable clearness,  "  Lieb,  lieb." 

He  apparently  has  some  recognition  of  music,  for  when 
his  daughter  plays  a  familiar  air  on  the  piano  he  is  atten- 
tive and  seemingly  follows  it. 

Examination  of  this  patient  eight  months  later  reveals 
practically  the  same  condition  as  above  stated,  save  that 
the  word  deafness  is,  if  changed  at  all,  more  complete. 
The  hemianopsia  is  very  difficult  to  demonstrate,  and,  if 
it  exists,  it  is  very  slight.  The  only  change  of  any  im- 
port is  a  marked  echolalia  that  he  has  developed.  If  one 
says,  "  How  old  are  you  ?"  he  repeats  over  and  over,  "  You, 
you,"  with  a  rising  inflection  on  the  last  letter.  "  How  is 
papa?"  "Papa,  papa,"  repeated  and  repeated.  Usually 
he  takes  the  last  word  of  the  sentence  that  he  hears  and 


258  The  Faculty  of  Speech. 

echoes  it,  occasionally  the  last  two  words.  Such  as  "  Will 
you  have  an  orange?"  "An  orange,  an  orange,"  he  re- 
peats--the  "an"  with  great  vigor  and  clearness  of  enunci- 
ation and  with  a  rising  inflection  on  the  last  syllable  of 
orange.  Complex  words  he  occasionally  attempts  to  echo, 
but  he  does  not  succeed  in  so  doing.  There  is  still  a  de- 
gree of  that  condition  known  as  mind-blindness,  but  it  is 
not  so  conspicuous  as  when  he  was  first  seen. 

No  general  description  of  auditory  aphasia  can  be  given 
to  cover  every  case,  so  great  is  the  variation  in  individual 
instances.  In  some  cases  there  is  only  inability  to  inter- 
pret a  certain  language,  or  a  certain  dialect,  or  a  certain 
number  of  words.  For  instance,  there  are  a  number  of 
cases  on  record  in  which  persons  seemingly  as  familiar 
with  several  languages  as  with  one,  have  had  word-deaf- 
ness for  all  of  them  except  one,  and  that  one  the  mother 
tongue,  the  one  acquired  first.  Some  years  ago  I  had  a 
patient  who  was  employed  as  an  official  interpreter  at  the 
Immigration  office.  He  developed  a  very  slight  right-side 
hemiplegia,  which  soon  ameliorated  so  much  that  it  was 
scarcely  to  be  noticed  unless  examined  for,  but  he  had  a 
marked  degree  of  word  deafness  for  all  languages  except 
Swedish — his  mother  tongue — a  language  which  he  had  in 
later  years  rarely  used,  and  never  except  when  occasion 
or  necessity  compelled  him.  He  was  partially  word  deaf 
for  Swedish.  This  language  having  been  first  acquired, 
it  is  logical  to  infer  that  it  was  most  indelibly  imprinted 
in  his  speech  area  and  least  easily  destroyed. 

I  have  said  before  that  there  must  necessarily  be  as 
many  forms  of  auditory  aphasia  as  there  are  distinctive 
symbolic  sounds.  Spoken  speech  is  the  most  highly  sym- 


Sensory  Aphasia.  259 

bolic  ;  the  next  most  differentiated  is  music.  To  the  form 
of  aphasia  in  which  there  is  deafness  for  musical  notes,  the 
designation  tone  deafness  (musical  deafness)  is  given. 
Amusia  as  an  accompaniment  or  as  an  integral  part  of 
aphasia  has  been  studied  carefully  by  Edgren  in  recent 
years.  In  his  article  a  number  of  cases  are  cited  in  which 
the  auditory  form  of  amusia  has  been  subjected  to  criti- 
cal examination,  and  some  of  them  were  studied  in  the 
light  of  post-mortem  examination. 

Musical  deafness  is  almost  always  associated  with  word 
deafness,  but  there  have  been  a  few  cases  recorded  in 
which  it  occurred  apart  from  the  latter.  Such  is  an  in- 
stance cited  by  Brazier, '  in  which  a  famous  tenor  of  the 
Opera  Comique  was  suddenly  seized  during  a  performance 
of  an  opera  with  complete  amnesia  of  words  and  music ; 
neither  the  orchestra  nor  his  fellow-singers,  who  tried  to 
prompt  him,  succeeded  in  reviving  his  memory.  Another 
instance  in  which  the  tone  deafness  was  not  associated 
with  word  deafness  was  that  of  a  man  who  suffered  from 
attacks  of  ophthalmic  megrim,  during  which  there  were 
passing  attacks  of  motor  aphasia,  lasting  from  four  to  five 
hours.  On  one  occasion  there  was  no  aphasia  but  he  could 
not  distinguish  musical  airs.  The  "  Marseillaise,"  on  being 
played  by  a  military  band,  was  not  recognized ;  although 
he  could  hear  quite  well,  he  did  not  know  the  tune.  He 
knew  only  that  it  was  a  noise  of  brass. 

The  clinical  forms  of  amusia  are  strikingly  analogous 
to  the  clinical  forms  of  aphasia,  and  they  generally  accom- 
pany the  latter,  although  the  different  varieties  of  amusia 

1  Brazier:  "  Amusie  dans  1'aphasie."  Rev.  Philos.,  October,  1892,  p. 
337,  t.  xxxiv.  ' 


260  The  Faculty  of  Speech. 

have  some  clinical  independence.  The  cases  of  word 
deafness  and  tone  deafness  reported  by  Serieux1  and  by 
Dejerine?  may  be  taken  as  classical  examples.  In  the  case 
reported  by  the  first  mentioned  there  was  total  loss  of  the 
conception  of  spoken  words.  The  patient  remarked  that 
she  could  hear  the  words  very  well,  but  that  she  did  not 
understand  them.  The  most  familiar  tunes  when  played 
on  any  instrument  were  not  recognized.  "  Au  Claire  de 
la  Lune"  was  said  to  be  a  "dead  march."  Cafe  chantant 
music  was  designated  church  music,  etc. 

Lichtheim3  has  reported  a  very  instructive  example  of 
amusia.  His  patient  was  a  teacher  and  journalist,  who 
became  completely  word  deaf  after  a  second  attack  of  apo- 
plexy. Communication  with  the  patient  could  be  made 
only  in  writing.  He  heard  when  one  sang  or  whistled, 
but  he  did  not  recognize  the  melodies.  Concert  singing 
by  his  children  was  most  annoying  because  it  was  "  so 
noisy."  The  most  familiar  melodies,  such  as  "  Rufst  du 
mein  Vaterland,"  were  not  recognized. 

This  case  is  worthy  of  remark,  in  so  much  as  the  pa- 
tient wrote  facilely  and  correctly,  and  understood  every- 
thing that  he  read.  These  features,  I  venture  to  think, 
stamp  the  case  as  one  of  subcortical  sensory  aphasia. 

A  still  more  striking  example  of  subcortical  sensory 
aphasia  with  notal  amusia  is  that  reported  by  Pick,4  in 
which  there  was  loss  of  musical  recognition  with  preserva- 

1  Serieux  :  "  Sur  un  cas  de  surdite  verbale  pure."  Revue  de  Medecine, 
tfyi,  P-  733- 

4  Dejerine  :  "  Ce'cite  verbale."  Memoires  de  la  Societe  de  Biologic, 
February  27th,  1892. 

3  Lichtheim  :     "  Ueber    Aphasie."     Deutsches    Archiv  f.  klin.    Med., 
vol.  xxxvi.,  1885,  p.  238. 

4  Pick  :  Archiv  f.  Psychiatric,  1892,  p.  910. 


Sensory  Aphasia.  261 

tion  of  musical  expression  associated  with  word  deafness. 
All  other  disturbances  of  speech  and  writing  could  be  ex- 
cluded. When  the  brain  was  examined  it  was  found  that 
it  had  its  usual  normal  configuration,  save  that  the  convolu- 
tions were  rather  small.  The  patient  had  had  a  left-side 
hemiplegia,  and  changes  were  found  in  the  right  hemi- 
sphere to  explain  its  existence.  In  the  left  hemisphere 
there  was  a  subcortical  softening  of  the  posterior  half  of 
the  first  temporal  convolution  and  of  the  medullary  sub- 
stance of  the  adjacent  supramarginal  convolution,  which 
accounted  for  the  preservation  of  internal  speech  associ- 
ated with  word  deafness  and  loss  of  musical  recognition. 

Much  evidence  might  be  cited  to  show  that  there  is  a 
definite  representation  of  musical  memories,  viz.,  auditory 
perception  of  notes,  accords,  and  melodies,  in  the  first  and 
second  temporal  lobes  of  the  left  hemisphere.  Edgren' 
believes,  after  careful  weighing  of  the  facts  bearing  on 
this  allocation,  that  it  is  immediately  in  front  of  the  area 
for  word  memories.  The  indications  are  that  it  is  a  part 
functionally  and  anatomically  of  the  auditory  centre. 

Visual  Aphasia —  Verbal  Blindness —  Word  Blindness. 

This  is  a  form  of  aphasia  in  which  there  is  loss  of  the 
significance  of  written  or  printed  words,  although  the  words 
themselves  can  be  seen  with  the  usual  distinctness.  The 
designation  "word  blindness"  or  "verbal  blindness"  to  in- 
dicate the  inability  to  recognize  words  and  letters,  and  in- 
terpret what  they  stand  for,  is  a  very  unhappy  one,  because 
the  term  blindness  has  here  a  very  different  significance 

1  Edgren  :  "Amusie."  Deutsche  Zeitschrift  f.  Nervenheilkunde,  vol.  vi., 
1895,  p.  i. 


262  The  Faculty  of  Speech. 

than  that  given  it  in  every-day  use.  In  the  form  of  apha- 
sia which  is  described  under  the  caption  of  verbal  blind- 
ness the  patient  can  see  the  word  perfectly,  but  he  gathers 
no  meaning  from  it.  The  peripheral  visual  apparatus  is 
intact.  A  printed  page  of  a  language  previously  entirely 
familiar  to  the  patient  suffering  from  this  form  of  aphasia 
conveys  no  more  meaning  to  him  than  does  a  page  of 
Greek  or  Hebrew  to  the  illiterate,  or  a  page  of  Chinese 
symbols  to  him  who  reads  only  English,  although  he  sees 
with  the  customary  distinctness  the  letters  printed  or  writ- 
ten, and  he  may  even  be  able  to  tell  the  handwriting  of 
one  person  from  that  of  another.  As  in  word  deafness, 
in  the  literal  interpretation  of  the  term,  the  defect  is  not 
word  blindness  but  loss  of  the  significance  of  words. 
Words  seen  do  not  arouse  a  corresponding  content  of 
consciousness. 

Word  blindness  may  be  classified  according  to  the  de- 
gree of  its  completeness  and  according  to  the  kind  of  con- 
crete written  or  printed  symbols  which  we  associate  with 
ideas,  such  as  algebraic  symbols,  musical  notes,  geometri- 
cal figures,  hieroglyphics,  etc.,  that  the  patient  is  unable 
to  recognize.  When  the  unmodified  term  word  blindness 
is  used,  it  is  understood  that  other  forms  of  printed  and 
written  symbols  than  letters  and  words  are  seen  and  in- 
terpreted, and  that  they  call  forth  corresponding  ideas. 
Many  cases  are  on  record  in  which  a  patient  absolutely 
word  blind  was  able  to  have  roused  in  his  consciousness 
certain  ideas  or  thoughts  leading  to  efforts  of  judgment  by 
such  printed  or  written,  verbal  or  numeral  notation.  De- 
jerine  has  described  a  man  with  complete  word  blindness 
who  was  able  to  interpret  the  markings  on  goods  in  his 


Sensory  Aphasia.  263 

shop,  and  to  tell  customers  the  price.  In  other  words, 
written  letters  having  an  entirely  different  significance 
than  that  ordinarily  attached  to  them  quickly  called  up  a 
content  of  consciousness  which  he  was  able  to  associate 
with  previously  acquired  knowledge. 

I  have  already  mentioned  that  blindness  for  words  may 
be  met  with  as  an  isolated  condition.  Broadbent  in  1872 
was  the  first  to  note  such  occurrence,  but  it  was  not  until 
Kussmaul's  discussion  of  it  that  it  began  to  be  carefully 
studied.  The  visual  area  is  in  the  posterior  lobe  of  the 
brain.  It  is  made  up  of  two  more  or  less  distinct  centres  : 
a  visual  perceptive  centre  and  a  centre  in  which  are  stored 
the  visual  memory  of  words  and  other  symbols.  The  for- 
mer is  situated  on  the  mesial  surface  9!'  the  occipital  lobes 
in  the  enviromental  area  of  the  calcarine  fissure ;  the  latter 
(usually  known  as  the  visual  centre)  is  in  the  posterior 
portion  of  the  inferior  parietal  lobule,  the  angular  gyms, 
and  the  adjacent  margin  of  the  supramarginal  convolution 
which  curves  over  the  posterior  extremity  of  the  fissure  of 
Sylvius.  Destruction  of  this  centre  produces  a  form  of 
sensory  aphasia  in  which  there  are  inability  to  put  interpre- 
tation on  words  seen  and  consequent  inability  to  read — the 
condition  known  as  word  blindness,  alexia,  but  it  causes  no 
loss  of  visual  acuteness.  It  will  be  seen  later  on  that  the 
primary  visual  area  and  the  higher  visual  centre  are  fre- 
quently diseased  simultaneously,  but  the  symptoms  pro- 
duced by  each  can  be  differentiated.  In  these  cases  it  is 
to  be  understood  that  no  lesion  exists  in  the  peripheral 
visual  apparatus,  although  the  condition  known  as  homony- 
mous  hemianopsia,  which  will  be  referred  to  hereafter  in 
some  detail,  oftentimes  exists. 


264  The  Facility  of  Speech. 

If  cases  of  uncomplicated  word  blindness  existed,  the 
study  and  interpretation  of  their  symptomatology  would 
be  a  very  simple  matter ;  but  such  cases  do  not  exist. 
There  is  almost  always  some  association  of  motor  aphasia, 
agraphia,  and  word  deafness,  and  these  coincident  occur- 
rences make  the  interpretation  more  difficult.  In  addition 
to  the  fact  that  word  blindness  is  thus  complicated  with 
other  conditions,  it  is  to  be  remembered  that  word  blind- 
ness due  to  lesion  of  the  zone  of  language  is  some- 
times associated  with  right  homonymous  hemianopsia  or 
concentric  limitation  of  the  visual  fields,  on  account  of  the 
juxtaposition  of  the  optic  radiations  of  Gratiolet  to  the  an- 
gular gyrus  on  their  way  to  the  cortex  around  the  calcarine 
fissure.  Or,  to  express  this  anatomically,  there  is  fre- 
quently some  destruction  of  the  optic  projection  fibres  con- 
stituting the  radiations  of  Gratiolet  and  those  connecting 
the  area  in  which  visual  memories  are  stored,  the  angular 
gyrus,  with  the  primary  visual  centre  in  the  left  occipital 
lobe,  which  mirrors  objects  in  the  right  visual  fields  of 
both  eyes.  Recent  and  trustworthy  observations  prove 
beyond  cavil  that  destruction  of  the  higher  visual  centre 
in  the  angular  gyrus  and  supramarginal  convolution  does 
not  cause  hemianopsia,  nor  does  it  cause  concentric  con- 
traction of  the  visual  fields.  In  every  case,  therefore,  in 
which  hemianopsia  and  concentric  limitation  are  present, 
the  lesion  must  involve  either  the  primary  visual  centre 
in  the  cunei  or  that  band  of  white  fibres  which  is  the  back- 
ward prolongation  of  the  optic  tract  connecting  the  exter- 
nal geniculate  body,  the  anterior  quadrigeminal  bo/ly, 
and  the  thalamus  with  the  primary  visual  centre,  and 
known  as  the  radiations  of  Gratiolet.  I  am  at  a  loss  to 


Sensory  Aphasia.  265 

understand  why  Brissaud,1  while  admitting  that  there  are 
cases  of  cerebral  hemianopsia  without  verbal  blindness, 
denies  that  cases  of  verbal  blindness,  and  by  that  I  mean 

literal  verbal  blindness,  may  occur  without  hemianopsia 

facts  laid  down  by  Prevost  and  substantiated  by  the  work 
of  Dejerine  and  Serieux.  These  observers  have  put  on 
record  a  number  of  cases  which  lead  them  to  conclude  that 
lesion  of  the  visual  centre,  the  angular  gyrus,  causes  word 
blindness  and  agraphia,  but  does  not  cause  hemianopsia  if 
the  lesion  is  limited  to  the  gray  matter,  and  that  a  lesion 
of  the  primary  visual  centre  in  the  left  occipital  lobe  alone 
causes  right  homonymous  hemianopsia,  but  if  limited  to 
that  the  higher  visual  centre  remains  intact  and  the  pa- 
tient is  not  word  blind  so  long  as  the  latter  is  in  connec- 
tion with  the  primary  visual  centre  in  the  other  occipital 
lobe ;  but  if  a  lesion  should  cut  across  the  connection  be- 
tween both  primary  visual  centres  and  the  centre  in  the 
left  angular  gyrus,  the  patient  is  word  blind  but  not 
agraphic. 

Before  proceeding  to  a  discussion  of  visual  aphasia  I 
wish  to  record  the  following  case  of  true  sensory  aphasia 
in  which  visual  aphasia  was  the  leading  feature.  I  am 
under  obligations  to  Dr.  Joseph  Fraenkel  for  opportunity 
to  study  the  patient. 

R.    M ,  a  right-handed  woman ;    native  of  Russia ; 

forty-five  years  old.  She  is  married  and  has  borne  several 
children.  There  is  no  history  of  miscarriages  or  of 
syphilis.  She  has  now  what  seems  to  be  an  atypical  form 
of  Basedow's  disease,  the  only  attributable  cause  of  which 
is  emotional  shock.  She  complains  of  fever  and  pain 

1  Brissaud  :  "  Traitc  de  Mcdecine,"  vol.  vi. 


266  The  Faculty  of  Speech. 

around  the  heart.  Objectively  tachycardia,  exophthalmos, 
and  enlargement  of  the  thyroid  gland,  more  pronounced  on 
one  side,  are  very  evident.  A  year  or  more  ago  she  was  quite 
melancholy ;  then  she  got  very  much  better,  and  remained 
fairly  well  for  a  few  months.  The  symptoms  from  which 
she  now  suffers  came  on  very  abruptly,  about  eight  months 
before  she  came  to  the  hospital,  and  followed  an  attack  of 
pneumonia.  Shortly  before  she  came  to  the  hospital  she 
had  a  transitory  attack  of  right-side  hemiplegia ;  the  right 
side  of  the  face  and  the  right  arm  were  particularly  in- 
volved, and  the  right  leg  very  slightly.  Admitted  to  the 
hospital,  June  i6th,  1896;  died,  October  24th,  1896.  The 
notes  of  the  house  physician  previous  to  my  first  examina- 
tion are  as  follows : 

"  Futile  attempts  to  get  a  history,  patient  being  aphasic, 
this  condition  having  come  on,  it  is  said,  on  the  way  down 
from  the  ward  to  the  office.  She  appears  to  understand 
when  spoken  to,  but  her  answers  show  paraphasia  and  mo- 
tor aphasia.  She  cannot  read ;  does  not  understand  written 
words ;  laughs  frequently ;  is  very  active ;  soils  the  bed ; 
has  dyspnoea. 

"  Examination  :  Weight,  seventy-five  and  three-quarter 
pounds;  pulse  148,  arhythmical  and  irregular ;  respiration, 
42;  temperature,  99.5°  F. ;  skin  hot  and  dry.  Patient 
fidgety ;  slight  bed  sores ;  thyroid  gland  enlarged ;  has 
Basedow's  disease.  When  asked  to  do  simple  things, 
such  as  'Put  out  the  tongue/  'Give  me  your  hand,'  etc., 
she  seems  to  understand,  and  does  it  quickly  and  hastily. 
Favors  the  left  hand ;  the  right  arm  hangs  down  from  the 
body. 

"  July  2Oth,  1896  (one  day  later). — Aphasia  exists  ;  con- 
siderable psychical  bewilderment ;  her  vocabulary,  com- 
pared with  that  of  yesterday,  is  diminished.  There  is  well- 
marked  motor  paralysis  of  the  right  upper  extremity,  and 


Sensory  Aphasia.  267 

the  forearm  is  kept  in  a  semiflexed  position.  The  knee- 
jerks  are  nearly  equal  on  both  sides,  and  they  show  the 
peculiarity  of  being  increased  with  a  flaccid  condition  of 
the  lower  extremities.  There  is  distinct  hemianaesthesia 
on  the  right  side,  but  it  is  difficult  to  ascertain  of  what 
nature  this  is,  on  account  of  the  jabbering  character  of 
the  responses.  Examination  of  the  urine  reveals  the 
presence  of  albumin,  the  specific  gravity  being  1.028." 

Since  she  has  been  in  the  hospital  she  has  had  one  or 
two  recurrences  of  the  hemiplegia,  but  like  the  other  at- 
tacks they  were  transitory.  The  most  striking  feature  of 
the  case  in  looking  at  her  is  her  intense  restlessness  and 
the  rapidity  with  which  every  movement  is  performed. 
She  is  either  continually  moving  and  agitated,  or  talking 
strings  of  words  that  are  wholly  unintelligible.  She  gives 
the  impression  of  a  person  who  is  on  the  verge  of  bursting 
into  an  attack  of  acute  mania,  but  who  still  has  some  coh- 
trol  of  herself.  On  my  first  examination,  I  found  the 
patient  to  be  an  emaciated,  excited-looking  woman,  who, 
on  account  of  the  bulging  of  the  eyes,  the  never-ceasing 
physical  activity,  and  the  verboseness,  presented  a  strik- 
ing picture.  At  this  time  there  was  no  trace  of  the  pre- 
vious hemiplegic  attacks,  the  last  of  which  occurred  only 
a  few  weeks  before  the  examination.  The  patient  was 
sitting  up  in  bed ;  she  held  continually  a  folded  handker- 
chief or  a  towel  against  the  face  and  mouth  with  the  right 
hand,  for  what  purpose  I  could  not  learn,  but  there  was  no 
drooling.  Her  speech  possession  is  best  indicated  by  the 
following  stenographic  report : 

What  is  your  name?  Tanes— tanes— tanes.  (Then 
she  smiles,  looks  distressed,  turns  abruptly  and  reaches 
for  the  card  which  hangs  over  her  bed  and  on  which  her 
name,  age,  period  of  admission,  etc.,  are  written.  This 
she  holds  out  to  her  interlocutor  and  laughs.) 


268  The  Faculty  oj  Speech. 

How  old  are  you?  Sex — sex — vier — vier — fiinf — fiinf 
— (then,  with  the  same  rapidity  as  before,  points  to  the 
card). 

Are  you  married  ?     Sure — sure. 

Are  you  one  hundred  years  old?  Sure,  sure.  (It  must 
be  marked  here  that  the  lower  class  of  Polish  Jews  give 
wider  significance  and  usage  to  the  word  sure  than  does 
any  other  race,  and  it  is  necessary  to  bear  this  in  mind  in 
this  patient,  with  whom  the  word  "  sure"  seemed  to  be  a 
recurring  utterance.) 

How  many  children  have  you?  Four.  Sure,  sure, 
sure.  (All  this  with  the  greatest  facial  and  bodily  activ- 
ity and  emotional  display — smiling  and  laughing.) 

What  is  the  name  of  the  first  ?     Sexel. 

What  is  the  name  of  the  second?     Vier. 

What  is  the  name  of  the  third  ?  Fickel.  (These  are 
possible  Hebrew  words,  but  they  have  no  appropriate- 
ness.) 

What  is  your  husband's  name  ?     Fickel. 

What  is  your  mother's  name?     Finckel. 

Now,  Mrs.  M ,  quiet  yourself  (it  should  be  said  here 

that  the  patient  is  very  verbose,  continually  emitting  a 
string  of  words  which  have  no  sense  or  meaning),  and  tell 
me  slowly  all  about  your  sickness.  My  husband — my 
husband.  He  will  say,  explain.  I  can't.  Sure,  sure. 
Yesterday  morning  early — (then  she  repeats  a  string  of 
words  of  which  it  is  impossible  to  make  a  report,  which 
here  and  there  can  be  recognized  as  elements  of  Hebrew 
jargon,  but  the  larger  number  of  them  are  not  a  constitu- 
ent of  any  language,  nor  have  they  any  connection.  Their 
production  is  accompanied  by  great  motor  activity,  rest- 
lessness, gesticulation,  and  occasionally  the  word  "sure.") 

(Holding  up  a  spoon)  What  is  that  ?     A  book. 

Is  it  a  spoon  ?     Yes.      (Says  it  with  pleasure.) 


Sensory  Aphasia.  269 

(Holding  up  a  cup.)  A  cup.  (It  is  probable  that  she 
heard  the  word  cup.) 

(Holding  up  a  watch.)     A  thing  to  look  for  the  hour. 

(Holding  up  a  match.)     To  rub.     I  understand  all. 

(Holding  up  a  pencil.)     To  write. 

(Pointing  to  some  bread.)  To  eat.  (After  hearing  the 
word  "  bread"  uttered,  she  says  it  very  quickly  and  with 
avidity.) 

(Holding  up  a  key.)  Pickle  (German,  Schliissel). 
(Then  replies)  What  one  opens  with. 

(Holding  up  a  knife.)  (Making  a  motion  as  if  to  open 
it)  To  eat. 

Is  it  a  knife?     Sure  (repeats  jargon). 

She  is  given  a  handful  of  coins  and  asked  to  select  all 
the  five-cent  pieces,  but  she  is  entirely  unable  to  do  so. 
She  starts  in  as  if  she  fully  understood  what  she  was 
requested  to  do,  but  she  is  unable  to  do  what  is  asked. 

How  much  is  there  there?  Twelve,  six,  four  (and 
then  she  begins  to  laugh). 

(Shown  a  two-dollar  bill)  How  much  is  that?  Six,  six, 
six,  six. 

\Yill  you  please  count  for  me?  Six,  six,  seven,  eight, 
one  (then  gets  rather  emotional). 

On  being  asked  to  repeat  the  line,  "  Aus  tiefem  Schlaf 
bin  ich  erwacht,"  she  was  unable  to  do  so.  She  started 
with  "  aus"  and  then  poured  forth  a  jargon  interspersed 
with  "  sure,"  all  the  time  smiling,  grimacing,  gesticu- 
lating. 

Can  you  read  ?  Yes.  (She  is  given  the  text  of  a  very 
familiar  Hebrew  prayer,  and  asked  to  read  it,  but  she 
cannot  repeat  a  word  correctly.  She  is  unable  to  de- 
cipher either  words  or  letters.) 

When  an  interpreter  who  is  very  familiar  with  her  jar- 
gon asks  her  her  name,  she  repeats,  "  Weitl,  sceitl,  heitl, 


270  The  Faculty  of  Speech. 

weitl."  (It  is  thought  that  she  is  endeavoring  to  say 
"  Rachel."  All  this  time  she  is  talking  rapidly  and  ges- 
ticulating.) 

How  old  are  you  ?  Six  and  four,  and  two,  and  sure,  and 
sure. 

Are  you  married  ?     Sure,  sure. 

How  long?     Sixty-four,  sixty-five.      I  can't  remember. 

Now  try  and  count  again  for  me  ?  four,  six,  seven,  six, 
seven,  five,  six,  eight,  seven,  seven,  eight,  eight,  sixteen, 
forty-six,  six  and  four  and  five  and  six. 

Can  you  repeat  the  letters  of  the  alphabet  ?  She  begins 
to  say  the  same  figures  as  above. 

Her  people  say  that  she  was  formerly  able  to  read  and 
write.  She  is  now  given  the  printed  page  of  text  that 
she  should  be  familiar  with  if  she  had  been  able  to  read  a 
word.  She  cons  it  very  studiously  and  then  begins,  "  Six 
and  four  and  four  and  six,"  and  so  on  in  the  most  mixed-up 
fashion.  She  then  takes  an  individual  line  and  points  the 
words  out  with  the  finger,  and  as  she  points  to  a  word  and 
makes  some  articulate  sound  she  looks  up  at  the  physician 
inquiringly  as  if  for  corroboration.  It  is  impossible  to  say 
from  examination  of  the  vision  whether  or  not  there  is 
hemianopsia.  It  is  oftentimes  very  difficult  to  say  just  how 
much  she  recognizes  through  the  visual  sense.  I  ask  her 
to  look  at  my  watch  and  tell  me  what  hour  it  is.  She 
looks  carefully  and  says  it  is  nearly  five  (correct  time, 
4  130).  Is  it  ten  minutes  after  five?  Yes. 

And  sometimes  on  being  given  a  number  of  coins  and 
requested  to  match  them  she  does  it  very  accurately.  It 
is  absolutely  impossible  for  her  to  repeat  a  sentence  or  a 
few  connected  words. 

On  being  handed  a  pen  and  asked  to  write  she  makes 
a  show  as  if  she  were  about  to  write  (that  is,  she  seems  to 
recognize  fully  the  use  of  the  pen  or  pencil),  but  nothing 


Sensory  Aphasia.  271 

in  the  shape  of  writing  results.  There  is  complete 
agraphia.  Of  course  it  must  be  kept  in  mind  that  she 
has  a  very  severe  tremor;  but  this  is  not  sufficient  to 
prevent  the  formation  of  letters.  She  can  copy,  but  in  the 
most  laborious  and  servile  way. 

The  efforts  at  copying  figures  and  numbers  are  somewhat 
more  successful,  but  she  cannot  call  the  numerals  that  she 
is  trying  to  write.  A  tuning-fork,  a  watch,  etc.,  held  to 
the  ear  she  heard,  but  she  apparently  did  not  associate 
them  with  any  distinct  source  or  sound.  It  is  impossible 
to  test  her  for  possession  of  associative  faculties,  for 
aside  from  the  fact  that  she  does  not  indulge  in  foolish 
actions,  there  are  no  means  of  judging. 

In  order  to  show  the  slight  variation  in  her  symptoms 
I  append  a  protocol  of  an  examination  made  some  weeks 
later  on  the  24th  of  September : 

What  is  your  name?  Heitem,  weitel,  sure.  Can't  say 
it.  (All  the  time  she  is  talking  some  sort  of  jargon  of 
which  neither  I  nor  any  of  the  attendants  can  make  out  a 
syllable,  and  she  gesticulates  at  the  same  time.) 

How  old  are  you?  (Apparently  does  not  understand 
the  question.)  Question  repeated,  and  she  looks  inquir- 
ingly at  the  nurse  and  at  me,  and  then  says,  "  Six  and  four 
and  four  and  four,"  and  then  all  at  once  as  if  she  suddenly 
interpreted  the  question  she  points  to  her  card. 

Are  you  married?     Sure. 

How  long?  Six  and  four  and  four  and  six.  I  can't 
tell,  I  can't  remember;  sure.  (Always  after  an  apparent 
reply  she  goes  on  with  considerable  jargon,  then  smiles, 
laughs,  looks  around.  She  keeps  the  corner  of  her  shawl, 
or  a  napkin,  or  whatever  she  may  have  in  hand,  up  to  the 
right  side  of  the  mouth.) 

How  long  have  you  been  married  ?  Six  and  four,  sixty- 
five,  I  can't  say  it. 


272  The  Faculty  of  Speech, 

She  does  not  comprehend  questions  that  are  addressed 
to  her  in  writing,  and  although  she  essays  to  read  such 
questions  the  answers  are  not  at  all  a  propos.  Interro- 
gated in  this  fashion  she  looks  at  the  writing  eagerly, 
quickly,  and  knowingly,  but  when  she  starts  to  answer  it 
is  always  the  same,  "  Six  and  four,  weitel,"  etc.,  etc.  If 
one  smiles  incredulously,  he  is  pretty  apt  to  hear  "  Sure," 
etc. 

Tests  to  make  her  repeat  after  her  interlocutor  resulted 
the  same  as  determined  previously.  Sense  of  smell  seems 
acute,  but  whether  she  detects  the  individual  substance 
held  to  her  nostril  is  not  clear,  for  she  cannot  name  it 
properly. 

She  seems  to  know  the  use  of  things. 

Autopsy  (Dr.  Fraenkel) :  Asymmetry  of  the  skull,  shown 
by  bulging  of  the  right  parietal  boss.  Dura  and  sinuses 
normal.  Pia  of  the  convexity  normal.  The  Sylvian  vessels 
as  well  as  their  branches  are  normal.  Along  the  sulcus 
of  the  right  insula  there  are  three  yellowish-white  papules 
on  the  surface  of  the  cortex,  each  about  three  millimetres 
in  diameter.  These  lie  either  in  the  pia  or  upon  the  ex- 
treme surface  of  the  brain,  or  in  both  places.  In  the  left 
hemisphere  there  is  seen  at  the  posterior  portion  of  the 
inferior  parietal  lobule  a  soft  pultaceous  yellowish  mass, 
which  is  slightly  depressed  beneath  the  surface  of  the 
brain  cortex.  This  measured  four  centimetres  in  diame- 
ter. Where  this  softened  region  joins  the  surrounding 
brain  cortex  it  is  less  yellow  and  more  firm.  The  pulta- 
ceousness  is  most  pronounced  at  the  centre.  It  occupies 
the  angular  and  supramarginal  gyri,  not  completely  effac- 
ing both,  and  has  slight  impingement  on  the  superior 
temporal  in  its  posterior  portion  (Fig.  12).  The  depth 
of  this  softened  region  is  so  great  that  it  extends  through 
and  involves  the  outer  portion  of  the  posterior  arm  of  the 


Sensory  Aphasia. 


2/3 


internal  capsule  just  as  these  fibres  enter  the  basal  ganglia. 
The  occipital  lobe  is  slightly  encroached  upon.  The  right 
hemisphere  shows  a  recent  softening  of  the  posterior  por- 
tion of  the  third  frontal  convolution.  This  grayish  mass 
is  about  two  centimetres  in  diameter. 

The  areas  of  softening  in  the  right  side  of  the  brain 
were  of  very  recent  date  apparently,  and  they,  like  the 


FIG.  i2.-Shaded  Area  Indicates  Spot  of  Softening. 

one  on  the  left  side,  can  probably  have  their  origin  traced 
to  emboli  coming  from  the  hypertrophic  and  thrombotic 
auricular  appendix,  and  the  chronic  endocarditis, 
probable,  moreover,  that  the  lesion  on  the  right  side  of 
the  brain  had  nothing  to  do  with  determining  either  1 
aphasia  or  the  paralysis,  and  the  case  is  one  of  true  sensory 
aphasia,  the  word  blindness  being   the    most    pronnn 
feature.     The  comparatively  slight  degree  of  word  dea. 
ness  that  the  patient  presented  was  dependent  upon  t 
impingement  of  the  area  of  softening  in  the  inferior  pai 
tal  lobule  upon  the  posterior  end  of  the  superior  temporal. 
1 8 


274  The  Faculty  of  Speech. 

The  total  agraphia  and  alexia  are  of  course  "significant  of 
destruction  of  the  angular  gyrus,  and  the  paraphasia  and 
jargonaphasia  are  likewise  most  interpretable  in  the  light 
of  the  autopsical  findings. 

Word  blindness  in  its  simplest  form  entails  alexia,  in- 
ability to  read,  or  inability  to  get  any  information  from 
written  or  printed  symbols.  Naturally  there  are  various 
degrees  of  intensity  of  word  blindness.  The  patient  may 
be  unable  to  read  words,  and  yet  retain  the  faculty  of  rec- 
ognizing letters;  or,  on  the  other  hand,  this  may  also  be 
lost,  constituting  literal  as  well  as  verbal  blindness ;  or 
he  may  be  able  to  recognize  letters  and  unable  to  join 
them  in  syllables  (asyllabia).  For  instance,  Mierze- 
jewski '  has  described  a  case  as  a  form  of  caecitas  sylla- 
baris  et  verbalis  sed  non  literalis,  and  Badal,2  in  his  mono- 
graph, mentions  another  case  which  was  carefully  studied 
by  the  author.  The  patient  studied  by  Badal  could  read 
individual  letters,  but  he  could  not  combine  them  or  keep 
them  long  enough  in  memory  to  form  a  word.  This,  it 
will  be  readily  seen,  is  merely  a  difference  in  degree  and 
not  a  difference  in  species.  It  has  been  noted  in  excep- 
tional instances  that  a  patient  who  has  verbal  but  not  lit- 
eral blindness  is  able,  if  his  auditory  centre  is  intact,  to 
have  the  meaning  of  the  word  made  evident  to  him  by 
spelling  it  out.  For  instance,  though  he  cannot  read  the 
word  "  cat"  he  can  read  c-a-t  and  comprehend  what  the 
letters  stand  for.  This  conservation  of  the  ability  to  read 

1  Mierzejewski  :   "  Ein  Fall  von  Wortblindheit. "     Neurologisches  Cen- 
tralblatt,  p.  750,  1890. 

2  Badal  :     "  Contribution    a   1'etude    des    cecites     psychiques ;     alexie, 
agraphie,    hemianopsie    inferieure,  trouble   du   sens   de   1'espace."     Arch. 
d'Ophthal.,  p.  97,  1888. 


Sensory  Aphasia.  275 

individual  letters  when  the  sight  of  words  calls  up  in 
mind  no  corresponding  ideas  is  not  difficult  of  explana- 
tion. It  is  dependent  upon  the  mode  of  education  of  the 
individual.  Most  children,  and  indeed  all  until  recent 
years,  learned  to  read,  that  is,  learned  to  attach  certain 
significance  to  printed  and  written  words,  by  first  learning 
to  recognize  the  individual  letters  of  the  alphabet  and  to 
differentiate  them  one  from  another.  They  are  not  sup- 
posed to  associate  any  significance  with  such  acquisition. 
Recognition  of  the  letters  of  the  alphabet  is  attained  as 
the  result  of  prolonged  and  tedious  effort.  Later,  the 
child  joins  a  number 'of  letters  together  to  form  words, 
which  he  may  or  may  not  have  previously  heard,  but 
which  have  a  visual  and  auditory  individuality  and  which 
give  rise  to  a  distinct  content  of  consciousness,  and  the 
visual  and  auditory  memory  of  them  leaves  its  impress  upon 
the  cortex  of  the  angular  gyrus  and  the  first  temporal  con- 
volution of  the  left  hemisphere  in  right-handed  persons; 
of  the  right  hemisphere  in  left-handed  persons.  The 
early  acquisition  of  letters,  and  the  primitiveness  of  their 
registration,  explains  the  greater  tenaciousness  of  their 
possession  and  the  greater  difficulty  of  their  disintegration. 
At  the  present  day,  one  of  advanced  pedagogic  en- 
lightenment, children  are  no  longer  required  to  learn  let- 
ters before  syllables  and  words.  It  is  probable  that  in  a 
person  thus  educated  there  would  be  letter  blindness  co- 
incident with  word  blindness.  A  condition  somewhat 
analogous  to  that  of  variation  in  intensity  of  word  blind- 
ness is  that  in  which  a  patient  becomes  unable  to  read 
the  letters  and  words  of  one  or  more  languages  that  he 
had  previously  been  able  to  read  and  speak  perfectly, 


276  The  Faculty  of  Speech. 

while  still  retaining  the  capacity  to  read  other  languages. 
Cases  of  this  kind  are  by  no  means  common,  but  a  num  - 
ber  of  them  have  been  reported,  particularly  by  Charcot 
and  Pitres.  It  is  not  often  that  suc*h  a  condition  is  the 
only  disability,  object  blindness  and  some  degree  of 
mind  blindness  are  generally  associated  with  it.  In 
the  case  cited  by  Charcot,  for  example,  there  was  loss  of 
visual  memory  for  form  and  for  color,  for  objects  and  for 
places.  The  monuments,  houses,  landmarks,  streets,  etc., 
of  the  town  in  which  the  patient  had  lived  for  many  years, 
and  with  which  he  had  been  very  familiar,  all  seemed  new 
to  him.  Moreover,  he  did  not  recognize  the  members  of 
his  own  family ;  they  seemed  to  him  like  strangers.  Some 
writers  make  the  very  grave  error  of  confounding  these 
cases  of  object  blindness  and  mind  blindness  with  cases 
of  word  blindness. 

In  many  cases  of  visual  aphasia,  or  word  blindness,  the 
patient,  although  absolutely  unable  to  recognize  anything 
else,  still  tells  his  own  name  when  he  sees  it  written. 
But  unless  he  has  been  accustomed  to  see  it  in  print,  he 
will  not  recognize  it.  The  only  explanation  for  this  fact 
that  can  be  offered  is  that  the  individual's  name,  because 
of  his  long  experience  in  seeing  it,  in  writing  it,  in  hear- 
ing it,  is  more  deeply  printed  on  the  specialized  sensory 
area  of  the  brain  to  which  it  has  been  carried  by  the 
hearing  and  seeing  apparatuses.  In  such  cases  it  is  under- 
stood that  the  angular  gyrus  is  not  completely  destroyed. 
Oftentimes  the  patient  will  preserve  a  recognition  of  a 
number  of  other  words,  particularly  of  names  with  which 
he  has  been  for  a  long  time  familiar,  such  as  those  of  the 
members  of  his  family,  his  business,  his  place  of  resi- 


Sensory  Aphasia.  277 

dence,  the  church  of  which  he  is  a  member,  etc.,  and 
for  precisely  the  same  reason  that  he  recognizes  his 
name. 

Occasionally  cases  are  met  with  in  which  the  verbal 
blindness  is  so  very  slight  that  it  requires  careful  and 
persistent  examination  to  reveal  it.  This  is  particu- 
larly true  of  cases  in  which  the  symptom  of  word 
blindness  unfolds  itself  slowly,  and  of  cases  in  which 
there  has  been  a  considerable  degree  of  recovery.  In 
such  cases  the  patients  may  be  able  to  recognize  one  or 
two  words  of  a  sentence,  especially  the  substantives,  and 
from  them  they  gather  the  sense  of  the  phrase.  If  the  pa- 
tient is  not  an  educated  person,  the  examiner  may  be  misled 
at  first  by  the  readiness  with  which  the  patient  essays  to 
read,  but  there  is  that  about  his  actions  and  demeanor  that 
will  suggest  to  the  experienced  physician  that  the  patient 
is  guessing.  He  very  rarely  reads  right  along  unhesitat- 
ingly, as  one  usually  does.  He  watches  the  expression 
of  the  person  for  whom  he  is  reading,  and  at  the  end  of 
every  sentence  or  line  he  looks  up  and  asks,  "  Is  that 
right?"  heaves  a  sigh  of  relief  if  it  is,  and  turns  to 
again. 

It  is  a  well-known  fact  that  the  acquisition  of,  and  the 
memory  for,  figures  and  numerals  are  a  different  process 
than  that  for  letters,  and  it  is  also  known  that  the  memory 
for  the  latter  may  be  preserved  and  the  former  lost.  In- 
deed, it  is  not  so  very  rare  for  a  patient  to  be  word  and 
letter  blind  but  not  figure  blind.  A  very  instructive  case 
is  one  recently  reported  by  Hinshelwood,  in  which  a  man 
although  absolutely  letter  blind  could  read  figures  quickly 
and  with  the  greatest  readiness. 


278  The  Faculty  of  Speech. 

The  term  dyslexia  is  one  that  was  first  used  by  Berlin,1 
of  Stuttgart,  in  1886,  to  indicate  a  form  of  word  blindness 
which  differed  materially  from  the  ordinary  forms.  The 
first  patient  described  by  Berlin  was  a  man  sixty-six  years 
old,  who  had  been  forced  to  abandon  his  occupation  be- 
cause the  reading  of  printed  and  written  characters  had 
become  quite  impossible.  He  was  not  word  blind  in  the 
usual  sense  of  the  term.  He  could  pick  up  a  paper  and 
read  five  or  six  words  quite  correctly  and  get  full  appreci- 
ation of  their  meaning,  and  then  he  would  have  to  stop,  as 
the  words  had  no  longer  any  meaning  for  him.  After  he 
had  rested  for  a  short  time  he  could  go  on  and  read  a  few 
words  more.  There  was  precisely  the  same  difficulty 
with  letters  of  every  size.  On  being  asked  why  he  could 
not  read  he  gave  no  satisfactory  explanation.  The  letters 
did  not  become  dim  or  confused,  he  simply  could  not  read 
them.  Efforts  to  read  were  most  obnoxious  to  him,  so 
keenly  alive  was  he  to  his  infirmity.  Later,  the  patient 
developed  other,  cerebral  symptoms  and  eventually  died 
from  apoplexy.  Berlin'  looks  upon  the  symptom  as  a 
special  form  of  word  blindness  due  to  interruption  in  the 
conductivity  of  the  connecting  fibres  of  the  visual  centre, 
the  angular  gyms.  It  does  not  seem  to  me  necessary  to 
look  upon  the  symptom  as  an  exclusive  "  aphasia  of  con- 
duction," and  I  see  no  reason  for  not  believing  that  it  may 
be  due  to  a  partial  impairment  of  the  molecular  function 
of  the  centre  for  visual  memory,  a  condition  that  may  re- 
sult from  injurious  agencies  that  pervert  the  function  of 

1  Berlin  :  "  Weitere  Beobachtungen  tiber  Dyslexic  mit  Sectionsbefund." 
Berliner  klinische  Wochenschrift,  p.  522,  1886. 

4  Berlin  :  Archiv  f.  Psychiatric,  pp.  289-292,  1887. 


Sensory  Aphasia.  279 

this  area  without  causing  anatomical  destruction  of  it.  In 
such  a  condition  the  centre  is  capable  of  being  aroused 
for  the  memorial  recall  of  letters  and  words  for  a  short 
time,  then  it  becomes  exhausted.  After  it  has  time 
to  rest,  a  brief  period  of  excitability  follows.  I  am  in- 
clined to  this  view  of  it  particularly  from  the  fact  that  the 
symptom  is  not  accompanied  by  symptoms  pointing  to 
impaired  functioning  of  the  auditory  centre,  which  would 
be  the  case  if  the  disturbance  was  in  the  internuncial 
fibres  connecting  these  two  centres.  This  view  would 
seem  to  receive  further  corroboration  from  the  fact  that 
the  symptom  has  been  observed  a  number  of  times  in 
alcoholic  patients,  and  it  has  disappeared  when  the  use  of 
the  toxic  agency  was  abandoned.  This  view  is  in  har- 
mony with  the  genesis  of  alcoholic  visual  hallucinations 
which  are  so  often  of  an  extraordinarily  vivid  character, 
and  with  the  occurrence  of  alcoholic  retrograde  amnesia. 

Hinshelwood '  has  published  a  very  instructive  example 
of  dyslexia  due  to  alcohol.  His  patient  was  a  tailor, 
forty- nine  years  old,  who  before  his  present  trouble  was  a 
very  capable  workman.  Latterly,  on  starting  a  piece  of 
work,  he  forgot  how  to  proceed,  and  every  step  had  to 
be  -pointed  out  to  him  as  though  he  were  a  beginner. 
Even  then  he  would  make  the  absurdest  mistakes,  and 
after  he  had  sewed  parts  together  they  had  to  be  ripped. 
The  greater  part  of  his  time  in  the  shop  was  spent  in 
looking  for  things  that  he  would  put  out  of  his  hand,  such 
as  the  thimble,  needle,  glasses,  etc.,  so  that  finally  he  had 
to  be  dismissed.  A  rather  remarkable  feature  of  the  case 
was  that  he  frequently  lost  his  way  in  the  most  familiar 

1  Hinshelwood  :  Lancet,  December  2ist,  1895. 


280  The  Faculty  of  Speech. 

parts  of  the  city,  and  he  could  find  his  way  home  only 
with  the  greatest  difficulty,  even  over  a  route  that  he  had 
travelled  for  years.  The  difficulty  of  reading  was  very 
similar  to  that  described  by  Berlin.  The  patient  could 
read  a  few  words  and  then  he  would  completely  lose  the 
capacity  to  proceed.  The  letters,  though  seen  with  dis- 
tinctness on  first  endeavors  to  read,  would  lose  all  mean- 
ing when  he  continued  in  his  attempts  to  read.  There 
was  no  blurring  or  running  together  of  the  letters.  There 
was  no  disturbance  of  speech  or  deterioration  of  mental 
power,  while  memory  for  past  events  was  not  at  all  im- 
paired. The  patient  recovered  under  tonics. 

This  case  is  one  that  admits  of  interpretation  along  the 
lines  already  suggested.  The  effects  of  the  alcohol  would 
seem  to  have  been  first  and  particularly  upon  the  centre 
for  the  memorial  recall  of  printed  and  written  words,  which 
were  followed  later  by  affection  of  those  parts  in  which  are 
stored  the  visual  memory  of  objects,  and  finally,  and  to  a 
comparably  slight  degree,  upon  the  primary  visual  area 
which  reflects  the  images  of  things.  Hinshelwood  con- 
tends that  memories  for  form,  color,  etc.,  are  stored  up  in 
both  occipital  convolutions,  and  the  symptoms  of  his  case 
would  lend  credence  to  this  view.  It  would  seem  warrant- 
able to  suppose,  in  this  case  at  least,  that  the  seat  of  the 
disturbance  was  the  entire  visual  area,  the  primary  cen- 
tres, and  the  centre  for  the  visual  memories  of  words. 
The  integrity  of»  speech  and  the  fact  that  there  was  no  loss 
of  memory  for  past  events  show  that  the  auditory  word 
memories  could  be  revived  with  their  customary  vividness 
and  transmitted  to  the  articuiatory  kinaesthetic  centre.  It 
is  to  be  regretted  that  careful  tests  were  not  made  to  de- 


Sensory  Aphasia.  281 

termine  the  patient's  capacity  to  write,  for  the  auditory 
centre,  acting  with  its  customary  force,  should  send  im- 
pulses, which  have  a  marked  influence  in  arousing  the 
memory  of  graphic  images,  to  the  visual  centre. 

If  the  angular  gyrus  is  completely  destroyed,  the  fac- 
ulty of  writing  is  lost  with  it,  or,  perhaps  I  should  say,  if 
the  power  of  visual  memorial  recall  is  lost,  then  writing  is 
no  longer  possible.  In  those  cases  in  which  voluntary 
writing  is  preserved,  the  lesion,  involves  the  primary  visual 
centre,  and,  as  this  lesion  is  so  often  associated  with  right 
homonymous  hemianopsia,  the  patient  begins  to  write  at 
the  extreme  left  side  of  the  sheet  and  stops  in  the  middle 
of  the  page,  unless  he  takes  the  trouble  to  inform  himself 
by  mediation  of  the  tactual  sense  that  there  is  still  room 
on  the  line  and  pushes  the  sheet  toward  the  left  in  order 
that  it  may  be  brought  into  the  visual  field.  These  pa- 
tients, being  unable  to  read  what  they  have  written,  are 
totally  unconscious  of  any  errors, of  spelling  or  phrase- 
ology that  they  may  make,  although  they  may  put  the 
words  on  paper  in  as  orderly  a  fashion  as  they  were  able 
to  do  before  the  development  of  the  aphasia. 

If  the  auditory  centre  is  uninjured,  the  patient  is  able 
to  comprehend  what  is  read  to  him,  and  if  his  own  hand- 
writing is  read  he  may  be  able  to  detect  errors  of  se- 
quence, of  diction,  and  of  spelling,  but  he  is  unable  to 
take  a  pen  and  correct  them,  because  he  does  not  recognize 
and  appreciate  the  value  of  a  word  or  a  letter.  Patients 
who  have  word  blindness  will  occasionally  take  a  paper, 
a  book  or  written  matter  and  essay  to  read  aloud,  but 
naturally  what  they  produce  has  no  connection  with  the 
subject  matter  before  them.  Why  they  do  this  is  difficult 


282  The  Faculty  of  Speech. 

of  explanation.     In  many  instances  it  has  been  the  reason 
for  considering  the  person  to  be  demented. 

Patients  with  word  blindness  are  sometimes  able  to  read 
written  or  printed  words  and  sentences  by  tracing  the 
word  (which,  it  is  to  be  remembered,  they  see  with  cus- 
tomary acuteness)  with  the  end  of  the  index  finger  or  with 
a  pencil.  This  is  a  most  instructive  phenomenon,  and, 
although  it  is  not  often  elicitable,  it  is  by  no  means  very 
rare  and  it  should  be  studied  carefully  in  every  case. 
Such  patients  by  utilizing  kinaesthetic  stimuli  excite  pre- 
vious kinaesthetic  memories,  which  in  turn  react  upon  or 
act  conjointly  with  auditory  and  articulatory  memories  to 
revive  the  mental  concept  of  the  word,  the  idea  that  it 
represents.  In  other  words,  the  kinaesthetic  apperceptive 
area  acts  vicariously  for  the  visual,  and  if  it  acts  more 
slowly  and  with  less  certainty  it  is  because  it  is  neither 
ontogenetically  nor  phylogenetically  intended  for  that  pur- 
pose, while  the  visual  area  is.  This  should  not  be  con- 
strued, I  think,  as  a  revivification  by  "motor  processes," 
as  taught  by  Strieker  and  others.  The  idea  of  the  word 
is  revived  by  kinaesthetic  stimuli  which  consist  of  sensory 
impressions  coming  from  the  muscles,  joints,  and  skin  of 
the  hand  and  upper  extremity.  Patients  who  practice 
perseveringly  this  method  of  conveying  to  their  minds  the 
meaning  of  written  symbols,  often  acquire  great  facility 
with  this  mode  of  interpretation.  The  principle  involved 
does  not  differ  materially  from  that  by  which  the  con- 
genitally  or  accidentally  blind  acquire  ideas  of  form,  of 
space,  of  size,  of  quality,  and  even  of  color,  in  which 
association  becomes  established  between  the  auditory 
centre  and  various  parts  of  the  somaesthetic  area. 


Sensory  Aphasia.  283 

The  fact  that  such  patients  interpret  by  tracing  written 
characters  more  readily  than  by  tracing  printed,  indicates 
that  muscular  sense  and  the  centre  of  graphic  motor  co-or- 
dination are  the  elements  that  mediate  the  connection  of 
the  word  and  the  concept,  for  in  every  person  the  training 
of  the  hand  has  been  to  trace  written  and  not  printed  sym- 
bols. These  patients  read  the  movements  of  which  the 
letters  are  the  tracing,  the  usual  pathway  between  the  word 
and  the  concept  in  the  revivification  of  visual  images  being 
destroyed.  In  some  cases  there  is  complete  inability  to 
read  printed  or  written  characters,  while  the  recognition 
of  musical  notes,  of  figures,  and  of  various  other  expres- 
sive symbols  is  preserved.  In  other  words,  there  is  a  dif- 
ferentiation of  graphic  symbols,  just  as  we  have  seen  a 
differentiation  of  auditory  symbols,  and  the  more  highly 
differentiated  these  symbols  are  the  more  completely  and 
easily  are  they  lost.  The  denomination  of  money  and  its 
representative  value  may  be  quickly  and  thoroughly 
grasped;  the  patient  may  retain  any  skill  which  he  may 
have  possessed  in  playing  cards  and  in  giving  perception 
to  symbolic  formula  other  than  those  represented  by  let- 
ters, all  of  which  tends  to  show  that  the  storage  of  written 
symbols  is  not  the  same  as  it  is  for  other  forms  of  nota- 
tion. 

It  should  not,  however,  be  understood  that  the  patient 
may  not  be  blind  to  all  forms  of  notation,  graphic  and 
symbolic  representation.  Thus,  there  may  be  sensory 
amusia,  sensory  asymbolia,  sensory  amimia,  etc.  The  oc- 
currence of  these  will  vary  with  the  composition  and  char- 
acter of  the  patient's  intellectual  possessions.  A  musician 
who  has  been  accustomed  to  carrying  simple  or  most  in- 


284  The  Faculty  of  Speech. 

tricate  themes  by  means  of  musical  notation  may  gaze  on 
scales  without  their  having  any  other  signification  for  him 
than  they  have  for  a  person  who  has  never  seen  a  page  of 
music.  He  may  also  watch  the  movements  of  a  leader's 
baton  while  they  give  no  more  orientation  for  the  execu- 
tion of  a  piece  of  music  which  he  may  be  able  to  play  by 
revivification  of  auditory  memories  than  would  a  person 
who  had  never  heard  of  tempo. 

Musicians,  by  virtue  of  the  acquisition  of  a  unique 
method  of  eye  externalization,  are  in  possession  of  special- 
ized sensory  images,  visual  and  auditory,  entirely  divorced 
from  the  memory  of  letters,  of  words,  and  of  figures,  which 
probably  posit  for  their  possession  different  cells  or  asso- 
ciation tracts,  and  the  one  may  fail  to  be  revivified  when 
the  eye  falls  on  it,  as  it  appears  on  paper,  while  others  are 
called  up  by  gazing  on  their  like. 

It  is  my  desire  to  make  as  clear  as  possible  that  the 
patient  with  visual  aphasia,  word-blindness,  sees  with  per- 
fect distinctness  the  letters  in  his  visual  field.  This  is 
done  by  virtue  of  the  primary  visual  area  in  the  occipital 
lobe,  but  the  reflection  of  letters  by  the  primary  visual  area 
does  not  convey  anything  to  the  intelligence,  it  does  not 
call  up  any  memory  pictures,  for  the  area  in  which  they 
have  been  stored  is  destroyed.  The  primary  visual  area 
reflects  letters  and  words  as  a  mirror  does  an  object  held 
up  before  it,  except  that  there  is  no  reversal,  and  as  reflec- 
tions by  a  mirror  make  no  impression  which  remains  after 
the  object  reflected  is  taken  away,  neither  do  words  make 
any  impression  because  of  the  impingement  of  their 
images  on  the  primary  visual  area.  Destruction  of  the 
primary  visual  area  produces  blindness  in  the  literal  sense 


Sensory  Aphasia. 


285 


of  the  word;  there  is  loss  of  perception  of  luminous  ob- 
jects, virtually  the  same  kind  of  blindness  as  when  the 
retime  are  destroyed.  When  the  primary  visual  area  of 


FlG.  13.— Course  of  the  Optic  Fibres.    EGB,  External  Reniculate  body;  AQB, 

anterior   qiuulrigeminal  body  ;   P  of  7\  pulvinar  ;    J'C,  visual  centre  ;  11','C, 
half-vision  centre. 

one  side  is  destroyed,  the  blindness  that  follows  is  of  half 
of  each  retinal  field,  and  on  account  of  the  partial  decussa- 
tion  in  the  chiasm  this  blindness  is  homonymous,  that  is, 
of  the  same  half.  This  visual  defect  is  shown  graphically 


286  The  Faculty  of  Speech. 

by  the  adjoining  figure,  which  is  based  upon  recent  knowl- 
edge-of  the  course  of  the  primary  optic  neuron. 

There  are  two  or  three  subdivisions  of  visual  aphasia,  to 
which  I  shall  refer.  The  first  is  a  form  in  which  there  is 
loss  of  the  perception  of  the  word,  not  only  of  the  visual 
impressions  corresponding  to  the  word,  but  a  loss  of  the 
value  of  the  symbol  in  arousing  the  idea  of  which  it  is  the 
written  representation.  This  form  of  sensory  visual 
aphasia  is  entitled  to  the  name  loss  of  word  visualization, 
verbal  amnesia,  or  psychic  blindness  of  words.  Unlike 
word  blindness,  the  patient  interprets  letters  as  letters  and 
words  as  words.  They  are  not  simply  marks  on  paper, 
and  he  can  read  them  and  copy  them,  but  they  convey  no 
meaning  to  him  after  he  has  read  them.  When  they  are 
pronounced  before  him  he  hears  and  interprets  them  very 
readily;  but  he  has  no  idea  that  they  are  the  same  words 
that  he  has  been  reading  or  copying  unless  he  is  so  in- 
formed. It  has  been  suggested  that  psychic  blindness  of 
words  is  a  phenomenon  exactly  analogous  to  that  which 
occurs  on  reading  a  book  when  our  attention  is  absorbed 
with  something  entirely  apart  from  the  subject  matter  be- 
fore us ;  we  read  on,  line  after  line,  we  reach  the  bottom 
of  the  page,  and  not  until  the  necessity  for  turning  the 
page  arouses  us  do  we  find  that  although  the  page  has 
been  faithfully  read  not  a  word  has  entered  into  con- 
sciousness, nor  can  we  cite  a  single  fact  that  the  writer 
attempted  to  convey. 

It  is  unnecessary  to  dwell  upon  the  difference  between 
this  and  letter  blindness  and  word  blindness.  It  is  read- 
ily seen  that  the  lesion  which  produces  such  a  condition 
must  be  one  that  interferes  with  the  pathway  that  conveys 


Sensory  Aphasia.  287 

the  sensation  from  the  printed  word  or  object  to  the  idea, 
or  to  where  the  idea  is  formed ;  and  we  are  warranted  in 
saying  that  such  interference  is  nearer  the  seat  of  con- 
sciousness, wherever  that  may  be,  than  it  is  to  the  seat  of 
memory  images  of  words. 

A  second  subdivision  is  that  in  which  the  patient  on 
looking  at  an  object,  which  he  has  previously  seen  and 
used  is  unable  to  call  up  its  name,  although  he  is  in 
condition  to  utter  the  name  if  he  could  call  it  up.  This 
is  the  condition  to  which  the  name  optic  aphasia  has  been 
given  by  Freund.  The  striking  symptom  is  the  inability 
to  name  things.  This  inability  is  not  difficult  of  interpre- 
tation. It  depends  upon  an  interruption  of  the  pathways 
that  unite  the  seat  of  cortical  visual  representation  and  the 
seat  of  cortical  auditory  memories.  It  is  necessary  in  order 
to  enunciate  a  name  to  influence  articulatory  images  through 
the  auditory  centre ;  in  other  words,  the  impulse  that  starts 
the  externalization  of  a  name  travels  along  the  intercentral 
(or  internuncial)  auditory-articulatory  pathway,  and  if 
auditory  images  are  properly  revived,  and  there  be  no  dis- 
turbance of  the  articulatory  kinaesthetic  area,  the  name 
will  be  uttered.  If,  however,  something  prevents  the  im- 
pulse from  passing  through  the  visual  apparatus  by  which 
one  gets  a  visual  concept  of  the  object  and  thus  from 
reacting  on  the  seat  of  auditory  speech  images,  then 
calling  objects  by  their  names,  when  such  are  presented 
to  the  peripheral  organ  of  the  visual  apparatus,  will  be 
entirely  impossible.  On  the  other  hand,  if  the  object 
is  of  such  a  nature  that  it  can  appeal  directly  to  the  audi- 
tory apparatus,  the  auditory  mechanism  being  intact,  the 
name  may  still  be  produced.  One  or  two  simple  examples 


288  The  Faculty  of  Speech. 

will  suffice  to  show  this  clearly.  If  a  photograph  be  held 
before  an  individual  and  he  is  asked  to  designate  it  by 
name,  an  impulse  travels  from  the  percipient  ocular  ap- 
paratus to  the  primary  visual  centres  and  to  the  higher 
visual  centre,  and  the  impression  thus  produced  will  excite 
the  auditory  centre,  to  which  the  articulatory  kinaesthetic 
area  is  subservient,  and  the  result  will  be  the  enuncia- 
tion of  the  word  "photograph."  On  the  other  hand,  if 
the  visual  mechanism  is  destroyed,  and  the  photograph  is 
held  to  the  ear,  the  patient  will  not  be  able  to  name  it, 
although  the  auditory  mechanism  is  intact.  The  photo- 
graph has  no  qualities  that  appeal  to  the  ear.  If,  how- 
ever, the  object  used  be  an  apple,  a  patient  with  loss  of 
visual  memories,  but  with  auditory  memories  intact,  may 
still  be  able  to  name  the  word  ''  apple"  if  the  object  be  pared 
and  sliced  within  his  hearing.  The  occurrence  of  this 
condition,  with  its  sharply  denned  symptomatology,  has 
led  certain  writers  to  allocate  special  portions  of  the  speech 
area  as  a  "concept  centre"  and  a  "naming  centre." 
Broadbent  was  the  first  to  advance  this  view,  in  a  paper 
published  in  1872.'  In  his  own  language:  "There  is  a 
primary  or  rudimentary  perceptive  act  in  which  the  exter- 
nal cause  of  a  given  set  of  sensations  is  recognized  as 
such,  and  in  which  the  simple  attributes,  as  of  form,  color, 
hardness,  etc.,  are  perceived.  And  there  is  a  higher  de- 
gree of  elaboration  in  which,  by  the  combination  or  fusion 
of  perceptions  derived  from  the  various  organs  of  sense, 
a  conception  or  an  idea  of  an  object  as  a  whole  is  obtained. 
This  is  a  new  and  distinct  process,  and  is  usually  accom- 
panied by  the  affixing  of  a  name  to  the  object.  The  higher 

1  Loc.  cit. 


Sensory  Aphasia.  289 

elaborations  and  the  fusion  of  various  perceptions  together, 
and  the  evolution  of  an  idea  out  of  them,  will  be  accom- 
panied not  by  radiation  from  one  perceptive  centre  to  all 
the  others,  but  by  convergence  of  impressions  from  the 
various  perceptive  centres  upon  a  common  intermediate 
cell  area,  in  which  a  process  analogous  to  the  translation 
of  an  impression  into  a  sensation  and  of  a  sensation  into 
a  primary  perception  will  form  a  part  of  the  supreme 
centre,  and  will  be  situated  in  the  superadded  convolutions 
which  receive  no  radiating  fibres."  In  the  further  elabo- 
ration of  this  theory,  Broadbent  postulated  a  "  proposition- 
izing"  centre,  in  which  words  other  than  substantives  were 
registered  and  in  which  words  were  arranged  orderly  pre- 
paratory to  being  uttered. 

It  seems  to  me  unnecessary  to  point  out  how  completely 
at  variance  this  is  with  the  conception  of  speech  that  I 
have  attempted  to  portray  in  another  chapter,  and  how 
contrary  it  is  to  the  idea  that  the  various  speech  centres 
have  an  integral  part  in  the  conception  of  words,  the  sym- 
bols of  thought.  The  existence  of  such  a  centre  is,  I  be- 
lieve, contrary  to  the  conception  of  the  psychogenesis  of 
speech.  The  reasoning  on  which  its  existence  is  posited 
is  fallacious,  and  the  cases  that  have  been  cited  to  estab- 
lish its  autonomy  are  made  to  .support  it  only  by  putting 
unwarrantable  interpretation  upon  accompanying  symp- 
toms. If  such  a  centre  existed,  it  is  reasonable  to  suppose 
that  cases  of  aphasia  would  have  been  described  before 
this  in  which  the  symptoms  pointed  to  the  destruction  of 
this  area,  especially  considering  the  autonomic  activity  that 
its  sponsors  give  it.  I  have  been  unable  to  find  any  such 
cases ;  that  is,  no  case  in  which  the  speech  disturbance 


290  The  Faculty  of  Speech. 

could  not  be  explained  by  a  lesion  of  one  of  the  speech 
centres  or  of  its  afferent  and  efferent  pathways.  The  case 
cited  by  Mills1  in  support  of  this  contention  is  reported  in 
such  an  incomplete  and  fragmentary  fashion  that  I  am 
astonished  that  one  of  his  clinical  astuteness  and  erudi- 
tion should  consent  to  offer  it  in  evidence.  The  follow- 
ing is  a  n'sum^  of  his  case  : 

A  woman,  forty-five  years  old,  complained  of  numbness 
in  the  back  of  the  head  and  neck,  vertigo,  and  vomiting. 
Soon  after  this  it  was  noticed  that  she  did  things  differently 
from  her  usual  custom.  She  hung  upside  down  a  certifi- 
cate of  membership  in  a  society  without  realizing  her  mis- 
take. She  had  to  forego  her  occupation,  that  of  dress- 
making, because  she  no  longer  got  the  parts  together 
properly,  etc.  In  othenwords,  she  developed  optic  apJiasia. 
(If  she  had  been  tested  there  would  have  been  found,  in 
all  probability,  dyslexia  or  alexia,  but  no  information  is 
given  concerning  the  reception,  interpretation,  or  emis- 
sion of  speech.)  About  three  years  after  these  symptoms 
were  first  noticed,  she  had  an  epileptic  fit,  and  after  this 
forgetfulness  of  words  became  very  evident.  Examina- 
tion showed  left  lateral  homonymous  hemianopsia,  word 
blindness,  but  not  letter  blindness,  inability  to  name  ob- 
jects, it  mattered  not  through  what  receptive  avenue  she 
got  information  concerning  them,  although  she  knew  their 
uses.  I  infer  there  was  Considerable  agraphia,  although 
nothing  'is  said  about  it,  for  a  fac-simile  of  the  patient's 
signature  shows  the  last  name  unfinished.  There  was 
slight  paraphasia  in  spontaneous  and  repeated  speech,  but 
the  former  soon  became  limited  to  the  use  of  "  Yes"  and 
"  No,  "  which  she  used  properly.  About  ten  weeks  before 
death  there  developed  slowly  a  right-side  hemiplegia.  On 

1  Mills  :  Journal  of  Nervous  and  Mental  Disease,  p.  i,  1895, 


Sensory  Aphasia.  291 

autopsy,  which  is  most  meagrely  reported,  there  was  found, 
on  cutting  into  the  temporal  lobe,  a  hard  tumor,  yellowish- 
brown  in  color.  Its  hardest  and  apparently  oldest  part 
was  in  the  middle  of  the  third  temporal  gyrus,  but  a  firm, 
nodulated,  more  or  less  hemorrhagic  condition  extended 
backward  as  far  as  the  white  matter  of  the  occipital  lobe 
and  forward  toward  the  anterior  ends  of  the  second  and 
third  temporal  convolutions.  It  was  thought  that  the  dis- 
ease started  in  the  third  temporal  convolution,  at  a  point 
in  line  with  the  posterior  extremity  of  the  horizontal 
branch  of  the  fissure  of  Sylvius. 

I  find  it  difficult  to  convince  myself  that  the  gradually 
developing  optic  aphasia  and  word  blindness  in  this  case 
were  due  to  anything  else  than  a  gradually  progressive 
lesion  which  encroached  upon  the  projection  tracts  of  the 
visual  fibres,  the  optic  radiations,  which  lesion  was  mani- 
fest by  such  infallible  evidence  as  homonymous  hemianop- 
sia,  and  which  later  severed  the  connections  between  the 
area  of  visual  and  auditory  speech  memories,  the  invoca- 
tion of  which  by  the  former  is  necessary  before  concrete 
words  can  be  used.  (Mills  reports  that  the  patient  had 
left  homonymous  hemianopsia,  which  I  take  it  refers  to 
the  retina,  and  not  to  the  visual  field;  in  other  words, 
blindness  of  the  right  side  of  the  fields.) 

The  patient  showed  optic  aphasia  by  her  inability  to 
recognize  that  a  certificate  was  hung  upside  down,  and  by 
her  inability  to  go  on  with  dressmaking.  This  sympt 
in  all  probability,  coincided  with  disturbance  between  the 
cortical  area  for  visual  reflection  in  the  cuncus  and  the 
area  in  which  visual  memories  are  stored  up  in  the  angu- 
lar gyrus.  That  the  interruption  became  more  profound 


2cj2  The  Faculty  of  Speech. 

and  extensive  is  shown  by  the  development  of  word  blind- 
ness and  homonymous  hemianopsia ;  that  it  never  became 
absolute  is  shown  by  her  continued  ability  to  recognize 
letters;  that  her  sensory  speech  area  became  gradually 
destroyed  is  shown  by  the  fact  that  she  became  almost,  if 
not  absolutely,  unproductive  of  voluntary  speech.  The 
area  of  articulatory  images  was  cut  off  from  the  centres 
that  excite  it  to  activity  and  control,  and  the  result  was 
almost  the  same  as  if  there  had  been  no  articulatory 
kinaesthetic  centre — a  locomotive  with  steam  but  without  a 
driver.  Moreover,  the  patient  was  not  wholly  agraphic, 
although  she  wrote  with  great  difficulty.  Now,  if  there 
is  any  one  fact  substantially  proven  in  sensory  aphasia,  it 
is  that  the  cases  of  aphasia  in  which  the  patient  is  word 
blind,  but  still  not  .agraphic,  are  dependent  upon  a  lesion 
in  the  white  matter  of  the  occipital  lobe  which  severs  the 
fibres  connecting  the  higher  visual  centre  with  both  of  the 
primary  visual  centres  in  the  two  hemispheres.  The 
lesions  found  on  post-mortem  examination  in  this  case 
show,  so  far  as  they  indicate  anything,  that  they  severed 
the  connection  of  the  auditory  centre  with  the  visual  cen- 
tre, and  the  connections  of  the  latter  with  the  primary 
visual  areas. 

In  addition  to  the  kind  of  visual  aphasia  in  which  there 
is  loss  of  memory  for  written  and  printed  letters,  and  to 
which  the  name  verbal  amnesia  or  psychic  blindness  of 
words  has  been  given,  there  is  a  form  of  less  common  but 
more  striking  occurrence,  known  as  psychic  blindness  or 
mind  blindness,  the  "  Seelenblindheit"  of  the  Germans, 
''  Cecite  psychique"  of  the  French,  a  condition  not  infre- 
quently associated  with  the  ordinary  form  of  word  blind- 


Sensory  Aphasia.  293 

ness  and  letter  blindness.  In  this  condition  the  patient 
not  only  does  not  recognize  the  significance  of  letters,  but 
he  loses  the  power  to  differentiate  between  familiar  ob- 
jects or  persons  and  to  distinguish  the  use  of  things.  He 
looks  at  a  member  of  his  own  family  and  sees,  apparently, 
a  stranger.  He  does  not  recognize  the  house  in  which  he 
has  lived  for  years,  neither  from  the  outside  nor  from 
within,  and  frequently  asks  when  lying  in  his  own  room 
when  he  is  to  be  taken  home.  Such  patients  do  not  rec- 
ognize a  washbasin  from  a  drinking-glass,  and  drink  as 
readily  from  one  as  from  another.  They  have  no  more 
conception  of  the  use  of  a  fork  or  of  a  spoon  than  has  an 
aborigine. 

The  condition  known  as  apraxia,  the  inability  to  com- 
prehend the  usage  of  ordinary  objects  and  things  to  which 
one  had  been  accustomed,  is  analogous  to  this.  Its  oc- 
currence and  misinterpretation  in  former  times  were  often 
responsible  for  getting  the  unfortunate  possessor  into  an 
asylum.  This  is  not  at  all  surprising  when  we  consider 
that  a  very  similar  symptom  often  occurs  during  the  very 
early  stages  of  general  paralysis.  A  patient  with  the 
latter  disease,  now  under  my  care,  first  showed  symptoms 
of  mental  illness  by  persistent  and  repeated  refusals  to 
enter  his  own  house,  insisting  that  the  one  in  which  he 
lived  looked  entirely  different.  Even  before  any  other 
symptoms  of  mental  disorganization  were  noted,  he  showed 
himself  quite  incapable  of  finding  his  house  or  the  street 
in  which  it  was  located,  or  of  recognizing  it  when  brought 
to  it.  A  similar  condition  is  often  seen  during  the  oc- 
currence of  very  severe  illness,  such  conditions  being 
looked  upon  as  the  visual  hallucinations  of  delirium. 


294  The  Faculty  of  SpcecJi. 

The  nature  of  the  condition  is  probably  an  abolition  of 
the  visual  memories  of  objects,  which  memories  have  been 
stored  up  in  the  higher  visual  area,  a  condition  analogous 
to  that  of  word  blindness.  The  patient  who  has  this 
condition  may  see  the  object;  that  is,  he  sees  it  objec- 
tively, but  he  does  not  see  it  subjectively.  When  we  are 
as  yet  small  children,  we  have  no  conception  of  the  uses 
of  a  great  many  things  that  impinge  themselves  on  our 
visual  apparatus,  which  afterward  become  very  familiar  to 
us.  In  the  acquisition  of  this  familiarity  there  is  stored 
up  in  the  higher  visual  centre  not  only  an  image  of  the 
object  itself,  but  with  it  a  memory  picture  of  its  use. 
This  latter  may  be  a  combined  kinaesthetic-auditory-visual 
one,  the  latter  being  for  most  objects  by  far  the  most 
important  one.  When  the  visual  image  is  lost,  the  mem- 
ory picture  cannot  be  rehabilitated.  As  Wyllie  has  re- 
marked, the  imprintation  or  storage  of  the  images  of 
objects  does  not  require  such  close  attention  as  the  im- 
printation or  storage  of  words,  and  the  images  of  objects 
and  things  are  stored  in  both  hemispheres  of  the  brain. 
This  would  account  in  a  measure  for  the  infrequent  occur- 
rence of  this  condition  even  in  cases  in  which  the  sensory 
speech  area  is  very  largely  destroyed.  It  would  also  lend 
itself  to  the  interpretation  of  the  occurrence  of  this  symp- 
tom in  the  early  stages  of  general  paresis,  in  which  the 
lesion  is  a  widespread  degeneration  of  the  cortex. 


CHAPTER    Ml.— (Continued-]. 

SUBCORTICAL    SENSORY    APHASIA. 

THE  subcortical  forms  of  sensory  aphasia,  pure  sensory 
aphasia  of  Dejerine,  are  analogous  to  the  subcortical  forms 
of  motor  aphasia.  In  discussing  subcortical  motor  aphasia, 
it  was  said  that  the  symptom  complex  attending  that  con- 
dition was  the  result  of  a  lesion  that  prevented  the  idea, 
properly  and  completely  formed,  from  being  externalized 
in  a  word  or  words.  In  similar  fashion  the  lesion  of  sub- 
cortical  sensory  aphasia  is  one  that  interferes  with  the 
passage  of  the  spoken  and  written  word  to  the  idea  of  the 
word  or  to  where  the  idea  is  formed,  it  being  understood 
that  the  structures  by  whose  functioning  the  idea  of  the 
word  is  formed  are  intact. 

The  real  components  of  sensory  aphasia  are  visual 
aphasia  and  auditory  aphasia,  and  it  follows  that  the  visual 
cortical  area  and  the  auditory  cortical  area  are  the  parts  by 
virtue  of  whose  activity  one  gets  a  visual  and  auditory 
idea  of  words.  Therefore,  there  may  be  a  subcortical  in- 
terruption of  the  visual  and  auditory  pathways  which 
causes  a  subcortical  visual  aphasia  and  a  subcortical  audi- 
tory aphasia.  I  shall  not  attempt  to  discuss  these  in 
extcnso  here,  as  I  have  already  referred  to  them  in  dis- 
cussing the  true  forms  of  sensory  aphasia. 

The  symptoms  of  subcortical  or/;/;r  visual  aphasia  will 
be  readily  understood  if  it  be  borne  in  mind  that  the  vi- 


296  The  Faculty  of  Speech. 

sual  centre  itself  is  intact  and  ready  to  functionate  and  that 
it  only  awaits  the  impulses  inciting  it  to  function  which 
proceed  from  the  half-vision  centres.  In  subcortical 
visual  aphasia  connection  with  the  primary  visual  centres 
is  severed,  and  consequently  the  higher  visual  centre, 
although  retentive  of  its  anatomical  integrity,  is  perverted 
in  its  physiological  ability.  The  connection  of  the  visual 
centre  with  the  other  speech  centres  is  not  disturbed,  ex- 
cept in  so  far  as  the  latter  are  not  properly  and  customarily 
influenced  on  account  of  the  fact  that  the  visual  centre  it- 
self does  not  itself  receive  customary  stimuli.  This  ac- 
counts for  the  occasional  occurrence  of  shortcomings  of 
speech  (slight  paraphasia,  such  as  noted  by  Bramwell), 
which  might  otherwise  seem  paradoxical. 

The  symptoms  of  subcortical  visual  aphasia  vary  some- 
what with  the  seat  of  the  lesion,  i.e.,  with  its  proximity  to 
the  left  angular  gyrus.  Generally  speaking,  they  are  verbal 
blindness,  always  associated  with  right  lateral  homony- 
mous  hemianopsia,  as  the  lesion  is  either  of  the  primary 
visual  area,  in  the  cortex  of  the  occipital  lobe  bordering 
on  the  calcarine  fissure,  or  of  the  optic  radiations  connect- 
ing the  occipital  lobes  with  the  left  angular  gyrus,  the 
higher  visual  centre.  The  patient  looks  at  printed  and  at 
written  letters  and  sees  only  black  marks  on  a  white  sur- 
face ;  he  is  wholly  unable  to  interpret  them,  because  the 
visual  impulse  is  prevented  from  reaching  the  left  angular 
gyrus,  in  which  such  impulses  are  interpreted  by  compar- 
ing them  with  the  residua  of  other  impulses  the  signifi- 
cance of  which  have  been  registered  in  consciousness  and 
which  are  known  as  memory  pictures.  The  fact  that  the 
centre  in  which  are  stored  such  visual  memory  images  is 


Subcortical  Sensory  -Aphasia.  297 

intact,  and  the  images  are  therefore  preserved,  can  be  shown 
in  a  variety  of  ways.  In  the  first  place,  they  can  be  re- 
vived through  kinaesthetic  stimuli.  If  the  patient  has 
been  long  habituated  to  writing,  it  may  be  possible  for 
him  to  interpret  the  significance  of  written  letters  and 
words  by  tracing  them  with  the  finger  end.  Printed  sym- 
bols remain  unintelligible  to  him,  because  he  has  not  been 
accustomed  to  tracing  printed  characters,  and  he  has  no 
kinaesthetic  memories  and  association  tracts  for  such  im- 
pulses which  can  proceed  to  the  angular  gyrus.  It  is  not 
always  possible  even  in  one  accustomed  to  writing  to  re- 
vivify visual  images  in  this  way.  In  the  second  place, 
patients  with  subcortical  visual  aphasia  retain  the  capacity 
to  spell.  Spelling  consists,  in  most  persons,  of  the  memo- 
rial recall  of  auditory  images  which  are  sent  to  the  other 
two  speech  centres,  the  articulatory  and  the  visual.  As 
these  centres  are  intact,  capacity  to  spell  is  undisturbed. 
Patients  with  subcortical  visual  aphasia  are  able  to  copy, 
but  they  delineate  without  deviation  from  the  copy  before 
them,  and  copy  print  in  print,  script  in  script. 

These  are  the  prominent  symptoms.  Spontaneous 
speech,  except  occasionally  the  slight  paraphasia  already 
referred  to,  and  capacity  to  repeat  are  intact.  The  pa- 
tient is  able  to  write  voluntarily  and  from  dictation,  but 
he  cannot  read  what  he  has  written  any  more  than  he  can 
read  what  some  one  else  has  written,  except  in  those  in- 
stances in  which  the  sense  can  be  gathered  from  tracing 
each  letter  with  the  finger  tip.  The  patient  understands 
readily  what  is  said  to  him  and  can  reply  intelligently  and 
correctly. 

Subcortical  visual  aphasia  may  or  may  not  be  accom- 


298  The  Faculty  of  SpeecJi. 

panied  by  a  degree  of  optic  aphasia  manifested  by  inability 
to  name  objects.  Whether  or  not  these  patients  have  any 
difficulty  in  spelling  needs  further  investigation.  In  all 
probability  they  do  not,  save  in  rare  instances.  Bramwell 
has  recorded  an  example  of  this  form  of  aphasia  in  which 
the  faculty  of  spelling  was  preserved  to  such  a  remarkable 
degree  that  the  patient  became  the  speller  for  the  family. 
As  an  example  of  subcortical  verbal  blindness  which 
is  every  way  typical  I  shall  cite  the  following  instance 
studied  in  my  clinic  at  the  Post-Graduate  Medical  School 
and  later  in  the  City  Hospital.1 

The  patient  is  a  male,  fifty-eight  years  old,  by  occupa- 
tion an  artisan,  whose  life  has  been  one  of  uniformity. 
Although  he  has  not  had  syphilis,  rheumatism,  or  gout, 
his  blood-vessels  show  well-marked  arterial  sclerotic 
change.  His  present  infirmity  dates  back  five  months. 
He  had  been  complaining  somewhat  of  not  feeling  well, 
of  headaches,  and  of  some  vertigo,  when  without  other 
warning  he  became  unconscious  and  lay  in  a  semi-uncon- 
scious, semi-delirious  condition  for  about  three  weeks. 
There  was  no  evidence  of  hemiplegia.  He  recovered  his 
mental  balance  after  three  weeks,  but  has  not  since  that 
time  been  able  to  return  to  his  occupation.  His  wife  says 
that  this  incapacity  is  the  result  of  bodily  weakness, 
forgetfulness,  and  because  he  does  not  remark  anything. 
He  comes  to  the  clinic  on  account  of  a  stupid  feeling 
in  the  head,  and  because  he  is  unable  to  work.  Exam- 
ination shows  that  voluntary  speech  is  without  notice- 

1  I  regard  the  case  as  particularly  valuable  because  of  the  corroboration 
which  the  examination  of  the  brain,  thus  far  made,  gives  to  the  statements 
made  from  clinical  data  alone.  The  patient  died  six  months  after  the 
monograph  had  left  the  author's  hand,  and,  as  will  be  seen  on  further  peru- 
sal, the  autopsy  fully  bears  out  the  diagnosis. 


Subcortical  Sensory  Aphasia.  299 

able  defects.  He  talks  in  a  somewhat  more  confiding 
way  and  with  a  little  more  emphasis  on  words  than  one 
usually  does,  and  occasionally  he  misplaces  a  word.  His 
wife  again  comes  to  our  aid  and  says  that  he  misuses 
words  at  home,  although  I  must  say  that  I  have  not  been 
able  to  remark  any  considerable  paraphasic  speech  dis- 
turbance, although  if  he  is  not  understood  quickly  he 
seems  to  get  impatient  and  with  a  gesture  significant  of 
impotence  he  turns  to  his  wife.  When  his  wife  is  asked 
to  cite  specific  examples  she  says  there  are  many,  but  she 
has  difficulty  in  recalling  one.  Finally,  she  says  that  if 
she  sent  him  to  a  shop  for  soap  he  would  be  quite  likely 
to  bring  back  flour.  This  surely  cannot  be  cited  as  a 
paraphasic  manifestation.  In  -repeating  sentences  there 
is  occasionally  sight  misplacement  of  words,  but  no  more, 
I  think,  than  would  be  expected  in  one  of  his  intellectual 
attainments.  Pantomime  and  mimicry  he  does  not  in- 
dulge in.  He  understands  what  is  said  to  him,  although 
he  is  not  quite  so  alert  as  formerly.  He  says  that  he  has 
to  be  attentive  to  what  is  said  to  him,  and  that  if  the  sen- 
tence is  very  long  he  loses  the  connection.  Examination 
of  the  eyes  shows  a  complete  lateral  homonymous  hemi- 
anopsia,  which  is  shown  by  the  accompanying  chart.  The 
patient  is  unable  to  read,  that  is,  there  is  complete  word 
blindness.  Occasionally  he  can  make  out  a  letter  here 
and  there,  but  there  is  almost  complete  letter  blindness. 
He  sees  the  letters  very  distinctly  and  is  able  to  tell  how 
many  letters  there  are  in  a  word,  but  he  is  totally  unable 
to  mark  off  a  word  into  syllables  or  to  take  a  number  of 
detached  letters  and  construct  a  word  or  syllable  out  of 
them.  There  is  no  object  blindness.  He  recognizes 
things  and  calls  them  by  their  right  names.  Voluntary 
writing  is  preserved,  but,  with  the  exception  of  his  name 
and  address  and  a  few  words,  he  is  not  productive.  After 


;oo 


77/6'  Faculty  of  Speech. 


writing  a  few  words,  he  foregoes  further  efforts  with  some 
despairing  remark.  He  writes  badly  to  dictation  after  the 
first  few  words,  the  writing  from  dictation  showing  only 
two  striking  features :  first,  he  is  apparently  unable  to 
retain  in  mind  a  sentence  sufficiently  long  to  write  it ; 
and,  second,  he  stops  the  line  before  he  gets  to  the  right 
side  of  the  page.  Writing  from  copy  is  very  defective ; 
what  he  copies  he  does  laboriously  and  servilely,  the  let- 


FIG.  14. — Complete  Lateral  Homonymous  Hemianopsia. 

ters  being  an  exact  reproduction  of  the  copy.  Script  is 
copied  as  script  and  print  as  print.  There  is  no  optic 
aphasia  or  mind  blindness.  The  patient  is  quite  as  intel- 
ligent as  are  most  people  of  his  age  and  social  position ; 
he  is  able  to  compute  mentally  and  to  spell,  and  is  in  fair 
possession  of  his  associative  faculties. 

In  the  examination  of  his  eyes,  it  was  interesting  to 
note  that  when  a  lighted  candle  was  brought  into  the 
right  visual  field  the  light  of  the  candle  was  not  seen  until 
after  it  had  passed  the  median  line,  although  the  patient 
detected  at  once  that  the  atmosphere  was  brighter  as  soon 


Snbcortical  Sensory  Aphasia.  301 

as  the  candle  was  brought  into  the  space  of  a  normal  visual 
field.  In  other  words,  as  soon  as  the  illumination  struck 
the  retina  he  said,  "  It's  brighter,"  but  he  did  not  see  the 
light. 

A   specimen    of    his   voluntary  writing   is    reproduced 
here.      It  is  an  attempt  on  his  part  to  tell  me  in  writing 

' 


FIG.   15.— Specimen  of  Voluntary  Writing. 

how  his  sickness  came  on — to  tell  me  all  about  it.  The 
words  have  no  significance.  So  far  as  they  can  be  made 
out  they  are  :  "  Dare  durg  [the  last  letter  is  really  nothing] 
akenbeit  ist  es  gekommen  ist  mochte  lesen,  ist  kann  nicht. 
Die  Krankheit  ist,"  etc.  When  I  ask  him  to  read  what  he 
has  written  he  begins  pointing  to  each  word  in  turn  "  Ich 
mochte  gern  lesen,  ich  mochte  gern  lesen" — all  this 
slowly  and  with  some  emphasis.  On  being  asked  to  spell 
the  individual  letters  entering  into  the  formation  of  each 
word  he  says,  pointing  to  the  first,  second,  third,  and  so 


302  The  Faculty  of  Speech. 

on,  "  That  is  e,  that  is  also  e,  that  is  e,  that  is  also  e,"  and 
so  on,  until  he  seems  to  become  tired. 

I  repeated  slowly  the  first  lines  of  Schiller's  poem, 
"  The  Casting  of  the  Bell"  : 

"  Fest  gemauert  in  der  Erden 

Steht  die  Form  aus  Lehm  gebrannt ; 
Heute  soil  die  Glocke  werden,"  etc. 

and  asked  him  to  write  them.  Although  this  was  re- 
peated line  by  line  and  he  could  say  it  himself  quite  well, 
the  following  is  a  fac-simile  of  what  he  produced  when  he 
endeavored  to  write  it  from  dictation  (Fig.  16)  : 

The  letters  are  formed,  and  some  of  the  words  are  real 
words ;  there  is  no  sense  in  them  or  any  suggestion  of 
the  original.  He  does  not  give  the  slightest  heed  to  com- 
mands addressed  him  in  writing,  such  as,  "Put  out  the 
tongue,"  although  he  responds  quickly  when  told  to  do  so 
in  spoken  words. 

In  this  case  the  symptoms  are,  briefly,  word  blindness, 
alexia,  right  lateral  homonymous  hemianopsia,  inability  to 
copy,  and  defective  writing  from  dictation.  Spontaneous 
speech  and  repeated  speech  are  not  disturbed,  nor  is  there 
noticeable  defect  in  the  interpretation  of  spoken  words. 
These  symptoms  and  possessions  point  to  a  lesion  between 
the  angular  gyrus  and  the  half -vision  centres  in  the  occi- 
pital lobes,  situated  in  the  posterior  end  of  the  left  hemi- 
sphere. The  fact  that  he  does  not  write  facilely  either 
spontaneously  or  from  dictation,  leads  me  to  believe  that 
the  lesion  is  situated  close  to  the  angular  gyrus  and  is 
perhaps  encroaching  upon  it. 

The  lesion,  which  was  originally  either  a  hemorrhage  or 
a  thrombosis,  must  have  so  completely  implicated  the  white 
matter  of  the  occipital  lobe  that  it  cut  across  the-  fibres 


Siibcortical  Sensor  \   .  \plictsia. 


303 


passing  from  both  occipital  lobes  to  the  left  angular  gyrus, 
involving   the    optic    radiations    of    Gratiolet.     The    fact 


tu 


FIG.  16.— Specime 


304  The  Faculty  of  Speech. 

that  there  are  word  blindness,  left  hemianopsia  without 
agraphia,  but  no  object  blindness,  shows  that  the  lesion 
cannot  be  either  in  the  primary  visual  centre  or  in  the 
higher  visual  centre.  For  if  it  were  in  the  primary  visual 
centre  there  would  be  object  blindness;  the  lesion  to  pro- 
duce hemianopsia  would  not  cause  word  blindness,  because 
in  such  a  case  the  higher  centre  would  still  be  in  connec- 
tion with  the  primary  occipital  area  of  the  other  side. 
The  lesion  is  not  in  the  higher  visual  centre,  because  if 
it  were  there  would  necessarily  be  agraphia  and  pro- 
nounced disturbance  of  internal  language,  while  in  reality 
neither  of  these  exists.  The  general  mental  infirmity  is 
no  greater  than  would  be  expected  from  an  intracranial 
lesion  so  grave  as  this  must  be,  and  in  a  patient  who  pre- 
sents the  striking  manifestations  of  vascular  degeneration 
that  this  one  does. 

So  much  for  the  clinical  deductions.  The  patient 
was  admitted  to  the  writer's  wards  in  the  City  Hospital, 
where  repeated  examinations  showed  no  material  depart- 
ures from  the  above-stated  findings.  Although  appar- 
ently a  docile,  tractable  individual,  it  was  found  that  he 
had  but  slight  control  of  his  temper,  and  when  aroused, 
oftentimes  even  when  not  excited,  he  indulged  in  profane 
and  vituperative  language,  which  was  directed  against  his 
attendants  and  those  about  him.  His  ability  to  create 
internal  language  and  to  externalize  it  in  spoken  words 
was  fully  evidenced  by  numerous  letters  sent  to  his  family 
which  were  dictated  to  a  fellow-patient.  His  health  was 
considered  to  be  in  fairly  satisfactory  condition  until 
November  8th,  1897.  On  the  afternoon  of  that  date  while 
sitting  on  a  bench  in  the  garden,  he  fell  over  suddenly 


Subcortical  Sensory  Aphasia.  305 

and  had  a  more  or  less  generalized  convulsion  accompanied 
by  frothing  at  the  mouth.  He  was  got  into  bed  imme- 
diately and  seen  a  few  minutes  later  by  the  house  physi- 
cian, who  reported  that  the  patient  did  not  utter  a  word 
or  apparently  recognize  any  one  after  the  attack,  but  grad- 
ually sank  into  unconsciousness,  and  meanwhile  a  right- 
side  hemiplegia  developed.  The  pupils  were  uneven, 
owing  to  contraction  of  the  left  pupil ;  the  face  was  flushed 
and  showed  a  right-side  palsy ;  the  axillary  temperature  was 
98.2°  F.  and  alike  on  both  sides ;  the  respirations  were  ster- 
torous, and  32  per  minute;  the  heart  was  working  labori- 
ously, while  the  pulse,  beating  84  times  a  minute,  was  very 
hard  and  firm.  Both  knee  jerks  were  absent.  The  uncon- 
sciousness deepened,  the  patient  vomited  copiously,  and 
soon  the  left  side  of  the  body  ceased  to  indulge  the  continu- 
ous movements  that  were  first  noticed.  Two  hours  after 
the  apoplexy  he  became  quadriplegic,  and  died  two  hours 
later,  about  four  hours  after  the  onset  of  the  symptoms. 

An  autopsical  examination  was  made  a  few  hours  after 
death,  and,  aside  from  the  changes  in  the  brain  about  to 
be  described,  there  was  no  noticeable  abnormality  save  an 
advanced  degree  of  arterio-sclerosis,  most  noticeable  in  the 
heart  and  large  blood-vessels  and  in  the  kidneys. 

The  skull  is  of  the  customary  thickness.  The  veins 
and  ctfploe  are  well  filled.  The  dura  is  easily  detached  and 
not  thickened,  and  the  brain  in  situ  looks  normal.  The 
pia  is  smooth  and  glistening  and  its  vascular  arborizations 
are  very  distinct.  Even  before  the  brain  is  removed  from 
the  calvarium,  but  more  conspicuously  after  removal,  a  most 
striking  abnormality  is  seen  at  the  posterior  pole  of  the 
left  hemisphere.  The  entire  occipital  lobe  looks  reddish- 


The  Faculty  of  Speech. 


yellow,  is  extremely  soft  to  the  touch;  in  fact,  the  lobe 
is  replaced  by  a  cystic  formation,  all  save  the  posterior 
extremity,  where  there  is  a  slight  cortical  mantle,  evidently 
not  yet  implicated.  When  the  fluid  of  the  cyst  escapes  the 
cortex  of  the  occipital  lobe  sinks  in,  and  the  superior 

surface  of  the  left  cerebel- 
lar  hemisphere  juts  prom- 
inently  into    view.      The 
same    yellowish-red   color 
and  the  same  pultaceous- 
ness  to  the  touch  are  ap- 
on     the    internal 
surface   of    the 
brain,    where    the 
destruction  of  tis- 
sue involves  nearly 

FIG.  17.— Shaded  Area  Shows  Extent  of   Lesion  on       n    <-u      v  1 

Mesial  Surface.  a11    the   "DgUal  gy- 


rus    and    the    cu- 

neus,  except  a  very  small  thin  surface  at  the  posterior 
pole  of  the  latter,  which  seems  to  have  retained  a  fairly 
normal  appearance  to  the  naked  eye. 

In  short,  the  cystic  formation  involves  the  whole  pos- 
terior part  of  the  left  hemisphere,  save  the  very  apex  of 
the  cuneus  and  particularly  the  inner  surface,  being  limited 
on  the  mesial  surface  (Fig.  17)  anteriorly  by  the  pajieto- 
occipital  fissure,  and  on  the  external  surface  by  the  pro- 
longations of  the  same  fissure.  The  gyri  involved  are 
the  first,  second,  and  third  occipital,  the  cuneus  and  lingual 
gyrus.  The  remainder  of  the  left  hemisphere  is  apparently 
normal  to  the  view  and  to  the  touch.  The  accompanying 
illustrations,  made  at  the  time  of  the  autopsy,  show  the 


Subcortical  Sensory  Aphasia.  307 

location  and  the  extent  of  the  lesion.  It  will  be  seen  that 
the  destruction  of  tissue  extends  anteriorly  as  far  as  the 
posterior  limits  of  the  inferior  parietal  lobule,  the  pre- 
cuneus,  and  the  angular  gyrus,  but  spares  these  absolutely. 
The  temporal  lobes  are  likewise  quite  unimplicated. 

The  depth  of  the  lesion,  originally  a  hemorrhage  which 
had  undergone  cystic  transformation,  was  almost  through 


FIG.  18.— Shaded  Area  Represents  Seat  of  Lesion. 

the  entire  thickness  of  the  white  matter  and  into  the  roof 
of  the  ventricle,  so  that  the  optic  radiations  were  completely 
cut  across.  When  the  isthmus  of  the  encephalon  was 
separated  by  a  horizontal  cut  of  the  pons  anteriorly  to  the 
apparent  origin  of  the  trigeminal  nerve,  the  cross-section 
showed  a  distention  of  the  aqueduct  with  sanious  fluid. 
When  the  two  hemispheres  were  separated  both  lateral 
ventricles  were  found  filled  with  clots,  the  left  much  dis- 
tended, the  foramen  of  Monro  and  the  middle  ventricle 
also  distended,  the  primary  fatal  hemorrhage  apparently 


308  The  Faculty  of  Speech. 

being  in  the  left  lateral  ventricle.  The  hemispheres  were 
then  cut  according  to  the  method  of  Flechsig  and  the 
brain  was  placed  in  Miiller's  fluid  for  hardening  prepara- 
tory to  further  study. 

This  observation  needs  no  further  remark,  save  to  say 
that  the  symptoms  which  had  been  present  were  so  accu- 
rately substantiated  by  the  post-mortem  findings  so  far 
determined  that  it  amounts  almost  to  the  exactness  of  a 
mathematical  demonstration. 

Subcortical  word  deafness,  or  pure  word  deafness  of 
Dejerine,  is  characterized  especially  by  inability  to  un- 
derstand spoken  words,  and  naturally  by  inability  to  write 
from  dictation,  because  the  spoken  word  of  another  cannot 
get  to  the  part  of  the  brain  in  which  the  idea  of  the  word 
is  interpreted.  It  is  of  much  less  frequent  occurrence 
than  subcortical  visual  aphasia.  The  feature  that  distin- 
guishes it  from  cortical  auditory  aphasia  is  the  fact  that 
spontaneous  speech  is  preserved,  there  is  no  amnesia 
verbalis,  the  patient  is  able  to  read  aloud,  to  write  volun- 
tarily, to  copy,  and  to  read  understandingly  what  he  and 
others  have  written.  As  in  every  other  form  of  subcorti- 
cal aphasia,  aphasia  in  which  the  zone  of  language  itself  is 
not  diseased,  every  constituent  of  internal  language  is 
intact.  It  is  rarely  if  ever  associated  with  paralysis  of 
the  extremities. 

A  classical  example  of  this  form  of  aphasia  is  that  cited 
by  Lichtheim.1  A  journalist  had  an  attack  of  apoplexy 
which  was  accompanied  by  pronounced  sensory  aphasia, 
from  which  he  made  a  partial  recovery.  Five  years  later 
he  had  a  second  attack  and  again  recovered,  but  this  time 

1  Loc.  at. 


Subcortical  Sensory  Aphasia.  309 

more  completely  than  before,  so  that  now  there  was  no 
difficulty  in  speaking,  in  reading,  or  in  writing.  He 
went  on  with  his  work  as  a  journalist.  He  was,  however, 
absolutely  word  and  tone  deaf,  although  hearing  remained 
quite  undiminished. 

It  has  been  mentioned  casually  in  another  connection 
that  recently  Bleuler,1  Freund,  and  other  writers  have  con- 
tended that  the  customary  conception  of  s.ubcortical  audi- 
tory aphasia  is  entirely  too  narrow,  confined  to  too  limited 
an  area,  and  that  it  should  be  enlarged  to  include  disease 
of  the  extracerebral  neural  structures  whose  functioning 
conditions  audition ;  at  least,  that  disease  of  the  peri- 
pheral auditory  neuron,  including  the  termination  of  the 
nerve  in  the  organ  of  Corti,  thus  taking  in  labyrinthine 
diseases,  should  be  included. 

Freund,2  in  a  recent  monograph  on  this  subject,  cites 
the  following  case,  in  which  bilateral  disease  of  the  laby- 
rinth following  epidemic  cerebro- spinal  meningitis  caused 
a  form  of  word  deafness : 

A  youth,  twenty-two  years  old,  by  occupation  a  watch- 
maker, developed  after  prolonged  physical  effort,  followed 
by  rapid  chilling  from  lying  on  the  cold,  damp  earth, 
symptoms  that  led  to  the  diagnosis  of  epidemic  cerebro- 
spinal  meningitis.  The  disease  was  of  the  severe  type, 
and  the  patient  did  not  convalesce  until  the  sixth  week. 
It  was  then  noticed  that,  in  addition  to  vertigo  and  pro- 
found disturbance  of  equilibration,  hearing  was  very  much 
impaired.  Soon  after  this  he  was  treated  in  the  otological 
clinic  of  Professor  Gruber  for  deafmutism. 

'Bleuler:    "  Zur   Auffassung    der  subcorticalen   Aphasieen." 
logisches  Centralblatt,  1892,  No.  18. 

2  C.  S.  Freund  :  "  Labyrinthtaubheit  und  Sprachtaubheit."  ^ 
1895. 


310  The  Faculty  of  Speech. 

An  examination  made  five  months  after  the  beginning 
of  the  illness  showed :  Loquaciousness ;  speech  rasping 
and  of  harsh  intonation ;  no  paraphasia  ;  no  optic  aphasia. 
The  patient  appeared  with  a  pad  and  pencil  for  the 
use  of  his  questioner,  as  he  claimed  to  be  wholly  unable 
to  hear  spoken  words.  There  was  no  disturbance  of  mo- 
tion, sensation,  or  vision.  There  were  slight  vertigo  and 
difficulty  of  maintaining  equilibrium.  Otoscopic  exami- 
nation of  the  ears  did  not  reveal  any  departure  from  the 
normal.  Examination  of  the  sense  of  hearing  showed  ab- 
solute deafness  on  the  left  side,  while  on  the  right  side  a 
few  vowels,  such  as  a,  e,  could  be  heard  when  they  were 
shouted  into  the  ear.  Aerial  conduction  of  notes  of  a 
tuning-fork  was  entirely  unperceived.  Bone  conduction 
of  the  same  was  unperceived,  although  the  patient  was 
sensible  of  the  mechanical  vibration. 

There  was  no  dyslexia  or  agraphia.  His  speech  was 
interfered  with  only  in  so  far  as  understanding  of  spoken 
words  was  entirely  lost,  and  naturally  there  was  inability 
to  repeat  spoken  words  and  to  write  from  dictation. 

All  acoustic  impressions  impinging  on  the  right  ear 
were,  when  not  too  low,  perceived  by  the  patient,  but  they 
were  not  properly  interpreted. 

In  order  to  determine  accurately  what  degree  of  com- 
prehension he  had  for  articulatory  sounds,  the  patient 
was  subjected  to  a  painstaking  examination.  The  vow- 
els and  consonants  were  shouted  separately  in  the  right 
car,  and  the  patient  was  apprised  in  writing  how  to  indi- 
cate when  he  had  heard  them,  what  he  had  heard,  and 
made  to  understand  fully  the  test  that  was  to  be  made. 

The  examination  showed  that  the  patient,  who  was  ap- 
parently completely  speech  deaf,  possessed  the  capacity  to 
grasp  during  the  examination  a  few  words  correctly  and 
others  very  nearly  correctly.  As  he  expressed  it,  "  I  hear 


Subcortical  Sensory  Aphasia.  311 

only  the  tone  of  the  words,  and  I  then  must  think  what 
they  can  be."  Perception  of  rhythm  was  well  preserved, 
and  he  had  good  conception  of  the  number  of  syllables  in 
the  uttered  word  and  the  intonation  that  was  given  to 
them.  When  asked  to  differentiate  between  the  words 
"December"  and  "June,"  he  did  so  with  readiness,  al- 
though he  was  often  unable  to  differentiate  between  words 
that  sound  somewhat  alike,  such  as  December  and  Sep- 
tember, or  June  and  July. 

The  patient's  intact,  spontaneous  speech  confirmed  the 
opinion  that  he  was  in  possession  of  his  auditory  word 
images.  Examination  of  his  music  -  perception  ability 
showed  that  he  did  not  hear  musical  sounds  so  clearly  as 
before  his  illness ;  for  instance,  he  was  unable  to  tune  a 
violin,  but  sounds  coming  from  the  street,  the  beating  of 
horses'  hoofs,  the  lumbering  roll  of  heavy  wagons,  the 
sprightly  sound  from  light  vehicles,  the  jingle  of  the 
tram-car  bells  were  heard  and  differentiated.  He  could 
differentiate  whistling,  the  snapping  of  fingers,  the  cluck- 
ing of  the  tongue,  the  clapping  of  hands,  etc.,  and  he 
very  seldom  erred  in  naming  the  source  of  such  sounds. 
He  could  likewise  indicate  the  origin  of  tones  from  a 
violin,  a  trumpet,  a  piano,  a  mouth  harmonica,  etc.  En- 
tire tones  he  differentiated  with  greater  readiness  than 
half-tones,  and  for  high  tones  there  was  striking  impair- 
ment. 

In  response  to  the  question  whether  he  could  hear  him- 
self talk,  he  remarked  that  he  could  hear  his  own  words 
but  not  clearly  and  distinctly,  and  the  more  trouble  he  had 
in  hearing  them  the  louder  he  spoke.  When  eating  he 
always  heard  ( ?)  the  grinding  noise  of  the  teeth. 

The  absolute  deafness  in  one  ear,  the  diminished  bone 
conduction  and  loss  of  perception  for  high  tones  in  the 
other,  the  normal  condition  on  examination  with  the  oto- 


3 1 2  The  Faculty  of  Speech. 

scope  excluded  absolutely  middle-ear  disease  and  bespoke  a 
disease  of  the  auditory  percipient  neural  mechanism,  due  to 
bilateral  labyrinth  disease  following  epidemic  cerebro- 
spinal  meningitis. 

I  have  quoted  this  case  in  detail  because  it  may  be  said 
that  no  unsurmountable  objection  can  be  raised  to  the 
admission  that  word  deafness  similar  clinically  to  that 
found  in  subcortical  sensory  aphasia  was  present.  The 
only  question  is  whether  one  is  willing  to  admit  that  the 
peripheral  auditory  neuron  can  be  normal  for  the  conduc- 
tion of  ordinary  sounds  and  diseased  for  the  conduction  of 
sounds  having  highly  differentiated  significance.  Person- 
ally I  see  no  objection  to  entering  such  cases  as  this  in 
the  category  of  subcortical  sensory  aphasia. 


CHAPTER    VII. 
TOTAL  APHASIA. 

OCCASIONALLY  cases  of  aphasia  are  encountered  in  which 
there  is  a  disturbance  of  all  forms  of  intellectual  expres- 
sion, involving  disturbance  in  the  reception  of  stimuli  that 
condition  mental  states  preparatory  to  speech,  and  dis- 
turbance in  the  emission  of  such  mental  states.  To  such 
cases  the  name  total  aphasia  is  given  because  it  includes 
the  phenomena  of  both  motor  and  sensory  aphasia. 

If  the  location  and  the  relationships  of  the  speech  cen- 
tres be  kept  in  mind,  the  existence  of  such  a  condition  will 
not  be  at  all  surprising.  The  speech  area  is  dependent 
for  its  blood  supply,  and  therefore  for  its  functional  integ- 
rity, upon  the  artery  of  the  fissure  of  Sylvius,  and  a  lesion 
of  this  artery  that  interferes  with  the  circulation  is  apt  to 
show  its  malign  consequences  in  every  part  dependent 
upon  the  artery  for  nutrition.  In  individual  cases  the 
area  supplied  by  one  of  its  branches  may  be  more  pro- 
foundly affected  than  another.  Thus  in  cases  of  total 
aphasia  we  sometimes  see  one  or  more  components  of  lan- 
guage less  wholly  submerged  than  others,  and,  on  the 
other  hand,  cases  are  seen  in  which  the  aphasia  in  the  be- 
ginning is  total,  yet  after  a  time  the  symptom  complex 
becomes  so  modified  that  one  of  the  modes  of  language 
may  be  partly  recovered. 


314  The  Faculty  of  Speech. 

As  an  example  of  total  aphasia,  1  may  cite  the  follow- 
ing instance : 

F.  C ,  thirty-eight  years  old,  a  native  of  Italy,  by 

occupation  a  bank  clerk.  He  is  married  and  the  father  of 
two  unhealthy  children.  His  wife  has  had  two  miscar- 
riages. There  is  no  way  of  determining  whether  he  has 
had  syphilis.  He  has  been  a  steady  drinker  for  many 
years.  After  he  had  suffered  from  a  condition  which  the 
family  physician  called  influenza  and  which  kept  him  in 
bed  for  about  two  weeks,  he  became  very  dizzy,  and  ex- 
perienced the  sensation  of  falling  while  passing  from  one 
room  to  another.  Soon  after  it  was  noticed  that  the 
right  upper  extremity  was  very  unwieldy  and  that  the 
right  side  of  the  face  was  somewhat  drawn,  and  that  he 
rapidly  became  unable  to  articulate.  In  fact,  save  for 
complaint  of  a  severe  pain  shooting  through  the  head  im- 
mediately after  the  occurrence,  of  the  vertiginous  spell,  he 
did  not  utter  a  word.  His  wife  says  that  there  was  not 
the  slightest  loss  of  consciousness,  but  that  the  patient 
was  "  out  of  his  head"  up  until  a  few  days  before  I  first 
saw  him,  which  was  six  weeks  after  the  onset  of  his  sick- 
ness. The  slight  hemiplegia  from  which  he  had  suffered 
disappeared  in  a  few  days.  His  wife,  furthermore,  states 
that  he  has  not  uttered  a  word  that  could  be  understood ; 
that  he  has  not  understood  what  was  said  to  him  ;  and  that 
he  has  not  essayed  to  read  since  the  beginning  of  his  ill- 
ness. She  says  that  he  is  in  his  right  mind,  that  he  does 
nothing  foolish,  except  to  watch  her  or  any  other  person 
who  may  be  in  the  room  with  embarrassing  persistency. 
Examination  shows  that  voluntary  speech  is  wholly 
lost,  and  that  he  makes  not  the  slightest  effort  to  re- 
peat when  he  is  instructed  to.  He  never  indicates 
wishes,  desires,  or  other  mental  states  by  pantomime,  and 
his  wife  tells  us  that  he  has  not  done  so  since  the  begin- 


f      | 


Total  Aphasia. 


3*5 


ning  of  the  illness.  When  he  is  given  a  pencil  and  asked 
to  write  he  makes  a  few  up-and-down  strokes,  but  frames 
no  letters  or  words.  On  being  requested  to  take  off  his 
coat  he  looks  intently  at  the  one  who  gives  the  command, 
watches  his  lips  most  carefully,  and  grunts  (nothing  ap- 
proaching articulation),  "  Sih,  sih."  After  the  request  is 
repeated  a  number  of  times,  each  succeeding  time  in  a 
louder  voice,  it  would  seem  that  he  gets  some  idea  of 
what  is  wanted,  for  he  grasps  the  lapel  of  the  coat,  but 
makes  no  further  effort  to  remove  it.  When  I  suggest 
my  request  by  aid  of  pantomime  by  throwing  off  my  own 
coat  and  then  pointing  to  his,  he  obeys.  To  the  command, 
"Put  out  your  tongue,"  a  number  of  times  repeated,  he 
closes  the  eyes.  When  he  is  asked  to  take  the  doctor's 
hand,  he  does  not  apparently  have  any  conception  of  what 
is  desired.  Under  further  questioning  and  commands,  he 
becomes  very  restless,  gives  vent  to  inarticulate  sounds, 
moves  the  lips  as  if  counting  or  mumbling,  twists  the 
fingers,  and  then  starts  to  go  out  of  the  room  as  if  he 
wished  to  go  home.  To  test  for  visual  perception  he  was 
shown  the  following  request,  first  in  writing  and  then  in 
print:  "Take  out  your  watch  and  show  me  the  time." 
No  response.  On  the  contrary,  after  adjusting  his  glasses, 
he  reaches  forward,  takes  the  pencil  from  my  hand, 
and  begins  to  copy  the  words  in  script.  On  endeavor- 
ing to  interpret  this  action  on  the  part  of  the  patient,  I 
learned  that  some  days  previously  he  had  been  given  a 
letter  addressed  to  his  employer  which  had  been  prepared 
by  his  brother  and  which  he  was  requested  to  copy.  This 
letter  set  forth  that  the  patient  was  not  very  ill,  was  not 
out  of  his  head  as  it  had  been  reported  to  his  employer, 
and  to  show  that  his  mental  faculties  were  unimpaired,  and 
that  his  position  should  be  kept  open  to  him,  this  letter 
written  by  his  own  hand  was  offered  in  evidence.  The 


316  The  Faculty  of  Speech. 

deception,  however,  did  not  work,  as  the  concocters  of  it 
had  never  been  able  to  get  the  patient  to  do  the  part 
allotted  to  him.  He  could  copy,  however,  and  he  copied 
script  in  script  and  print  in  print.  To  the  written  ques- 
tion, "How  old  are  you?"  first  in  printed  and  then  in 
written  characters,  he  takes  a  pencil  and  points  to  the 
individual  words,  at  the  same  time  making  this  inarticu- 
late "  Sih,  sih,  sih,"  and  then  he  starts  to  copy  it,  without, 
however,  giving  the  slightest  intimation  that  he  gets  the 
purport  of  the  question.  It  is  impossible  to  say  positively 
that  there  is  no  hemianopsia,  but  probably  there  is  not,  as 
thrusting  the  finger  abruptly  into  the  visual  field  causes 
prompt  blinking. 

There  is  no  optic  aphasia  nor  is  there  mind  blindness. 
The  patient  fully  recognizes  the  use  of  things.  On  being 
handed  a  watch,  he  opens  it,  looks  at  the  time,  compares 
it  with  the  clock  on  the  mantle,  and  returns  it.  On  being 
given  a  tuning-fork,  he  sets  it  in  vibration  and  holds  it  to 
the  ear.  He  feeds  himself,  dresses  himself,  and  goes  out 
alone,  and  in  a  general  way  deports  himself  as  does  a 
person  in  the  possession  of  his  faculties. 

Repeated  examinations  showed  no  considerable  depar- 
ture from  this  condition  for  some  time,  but  after  a  num- 
ber of  weeks  he  became  able  to  articulate  "  Yes"  and 
"  No,"  to  write  his  name,  that  of  his  father,  and  of  his 
wife,  and  to  give  evidence  that  he  understood  some  things 
that  were  said  to  him,  particularly  if  they  were  repeated  a 
number  of  times.  Voluntary  speech,  repetition  of  speech, 
still  remained  wholly  submerged.  Six  weeks  after  the 
first  examination,  on  being  asked  to  put  out  the  tongue, 
he  did  so ;  but  when  he  was  asked  to  go  into  the  next 
room  he  deported  himself  as  one  unaware  of  any  request. 
Still,  from  this  time  onward,  it  was  noted  that  he  took 
greater  heed  of  commands  and  requests  directed  to  him 


Total  Aphasia.  317 

through  the  hearing,  and  a  general  improvement  of  the 
word  deafness  followed.  On  being  asked  to  read  a  simple 
sentence,  he  takes  the  pencil  and  points  to  each  individual 
word,  accompanying  the  indications  with  the  utterance  of 
the  sounds  eh,  fa,  eh,  fa,  eh,  la,  fe,  eh,  la,  fe,  and  contin- 
ues to  do  this  throughout  an  entire  page,  pointing  to  each 
word.  If  the  sentence  embodies  a  simple  request,  he 
takes  no  notice  of  it.  Frequently,  after  going  through  a 
sentence  in  this  way  he  looks  up  at  the  examiner  inquir- 
ingly, then  shakes  his  head,  assumes  a  look  of  distress, 
draws  a  line  under  the  word,  and  goes  on.  He  is  now 
able  to  copy  fairly  well,  but  copies  line  for  line,  word  for 
word,  as  in  a  drawing.  In  the  same  way  he  is  able  to 
copy  simple  figures  and  designs.  He  is  totally  unable  to 
write  from  dictation  or  from  written  instructions.  If  he 
is  given  a  pencil  and  left  alone,  he  proceeds  to  write  his 
name,  then  the  surname  of  his  father,  and  then  that  of  his 
wife.  On  being  asked  where  he  lives,  he  writes  his  father's 
name ;  to  a  second  request,  he  writes  that  of  his  wife.  If 
the  question  is  asked  him  in  writing,  he  proceeds  to  copy 
the  question.  He  is  able  to  add  up  a  column  of  figures, 
but  the  results  are  not  usually  correct ;  in  fact,  they  are 
more  often  incorrect.  He  begins  at  the  top  of  a  column, 
points  to  the  figures,  and  often  says,  "  Feh,  lah,  feh,  feh, 
lah,"  giving  a  variable  intonation  to  each  one  of  these  utter- 
ances, then  scratches  his  head,  looks  disturbed,  goes  again 
to  the  top  of  the  column,  and  begins  all  over.  His  wife 
says  that  he  is  able  to  play  cards,  and  that  it  tickles  him 
very  much  to  win.  He  apparently  recognizes  the  numerals 
on  banknotes,  and  he  can  tell  time.  He  never  essays  to 
read  a  paper,  and  on  being  given  a  letter  from  his  parents 
commiserating  with  him  in  his  illness  he  takes  no  inter- 
est in  the  matter.  To  recapitulate  briefly,  this  man  has 
(i)  loss  of  spontaneous  speech;  (2)  inability  to  repeat 


318  The  Faculty  of  Speech. 

after  dictation ;  (3)  inability  to  indicate  desires  or  feelings 
by  means  of  mimicry;  (4)  inability  to  write  spontaneously 
(except  latterly  he  has  regained  the  ability  to  write  his 
own  name  and  that  of  his  wife  and  of  his  father) ;  (5)  in- 
ability to  write  from  dictation ;  (6)  letter  blindness,  word 
blindness,  alexia ;  (7)  partial  (in  the  beginning  complete) 
word  deafness — he  neither  understands  nor  obeys  spoken 
requests.  He  is  able  to  copy,  but  copies  exactly  the  words 
or  letters  that  are  put  before  him.  He  can  interpret  re- 
quests and  commands  made  to  him  by  pantomime ;  he  can 
play  cards  and  other  games ;  he  recognizes  the  use  of  things 
and  the  places  and  relations  of  objects;  he  can  look  at  a 
watch  and  transfer  to  paper  by  means  of  figures  the  hour 
indicated ;  there  is  no  trace  of  hemiplegia,  unless  it  be  a 
somewhat  lessened  activity  in  the  muscles  of  the  right 
side  of  the  face. 

This  case  shows,  therefore,  that  there  was  disturbance  of 
all  the  modes  by  which  one  person  communicates  with 
another,  both  receptively  and  emissively.  The  only  in- 
terpretation to  put  upon  it  is  that  after  the  tenancy  of  an 
acute  infectious  disease  a  thrombosis  formed  in  the  left 
Sylvian  artery,  which  robbed  the  speech  area  of  the  blood 
necessary  for  its  functioning.  That  this  pathological 
process  did  not  cause  a  serious  disturbance  of  other  func- 
tions of  the  brain  is  shown  by  the  fact  that  there  was  no 
loss  of  consciousness.  That  it  did  not  involve  the 
pyramidal  projection  is  shown  by  the  very  slight  and 
transitory  hemiplegia  which  left  no  sequelae,  as  organic 
hemiplegia  invariably  does.  That  there  was  some  involve- 
ment of  the  motor  cortex,  however,  is  shown  by  the  slight 
paresis  of  the  right  side  of  the  face  and  the  right  arm, 
which,  it  would  seem,  was  dependent  upon  disturbance  of 


Total  Aphasia.  319 

function  of  the  ascending  frontal  convolution  adjacent  to 
the  frontal  operculum.  After  the  thrombosis  or  whatever 
lesion  may  have  existed  was  partly  removed,  or  at  least 
after  the  circulatory  disturbance  which  it  produced  was  in 
part  compensated  for,  some  of  the  speech  centres  regained 
in  a  very  slight  way  their  functions,  and  this  was  particu- 
larly true  of  the  auditory  centre,  for  it  was  the  word  deaf- 
ness more  than  anything  else  that  showed  improvement. 
To  what  extent  improvement  will  still  go  on  cannot  be 
prophesied. 

A  very  important  and  instructive  case  of  complex 
aphasia  has  recently  been  reported  (although  not  yet  in 
detailed  form)  by  Bastian.1  A  right-handed  man  had  an 
attack  of  right  hemiplegia  with  loss  of  speech  three 
months  before  coming  under  observation.  Eighteen  years 
after  the  first  apoplectic  attack  a  thrombosis  of  the  right 
middle  cerebral  artery  caused  death.  When  the  patient 
was  first  seen  he  was  incompletely  paralyzed  on  the  right 
side,  and  there  was  also  incomplete  hemianaesthesia  on  the 
same  side.  For  six  years  after  the  first  apoplectic  stroke 
he  had  slight  convulsive  attacks  from  time  to  time. 
There  was  then  an  interval  of  twelve  years,  but  during  the 
last  year  of  his  life  he  had  three  severe  fits,  each  of  which 
was  followed  by  a  temporary  aggravation  of  the  paralysis  of 
the  right  side.  Within  two  months  of  his  coming  under  ob- 
servation his  speech  defects  assumed  the  form  which  they 
maintained  during  the  next  eighteen  years  with  remarka- 
ble constancy.  The  striking  features  of  the  man's  condi- 
tion were  as  follows : 

i.  Voluntary  speech  limited  to  a  few  words. 

1  Bastian:  Lancet,  vol.  i.,  1897. 


320  The  Faculty  of  Speccli. 

2.  Could  repeat  words  that  he  heard. 

3.  Understood  everything  that  was  said  to  him. 

4.  Inability  to  read  aloud.     (The  reporter  says  that  he 
spent  much  of  his  time  in  reading,  and  undoubtedly  un- 
derstood what  he  read,  yet   many  patients  with  sensory 
aphasia  spend   much   of   their  time   in   reading,  without 
comprehending  a  word. ) 

5.  Inability  to  write  a  word  from  dictation. 

6.  Inability  to  name  objects  at  sight. 

As  no  mention  is  made  of  hemianopsia  it  is  to  be 
inferred  that  it  was  not  present. 

The  autopsy  showed  a  complete  atrophy  of  the  convolu- 
tions in  the  territory  supplied  by  the  left  middle  cerebral 
artery.  The  atrophy  had  extended  inward  so  as  to  lay 
open  the  lateral  ventricle,  and  the  whole  of  this  region 
was  occupied  by  a  large  pseudo-cyst.  The  supramarginal 
and  angular  gyri,  as  well  as  the  posterior  two-thirds  of  the 
upper  temporal  convolution,  were  included  in  the  parts 
that  had  completely  disappeared. 

The  case  is  regarded  by  the  author  as  "  a  very  remarka- 
ble one ;  first,  because  of  the  complete  destruction  of  the 
supramarginal  and  angular  gyri  and  the  posterior  two- 
thirds  of  the  upper  temporal  convolution  without  the  oc- 
currence of  word  blindness  or  word  deafness."  This  would 
be  very  remarkable  indeed  if  it  were  so,  and  would  revolu- 
tionize in  a  measure  the  teachings  not  alone  of  aphasia 
but  of  cerebral  localization.  "  It  is  presumed,"  says  the 
author  in  attempting  to  explain  these  remarkable  anom- 
alies, "  that  the  atrophy  of  these  convolutions  must  have 
occurred  at  some  unknown  period  during  the  patient's  ill- 
ness ;  that  it  must  have  occurred  gradually,  and  that  func- 


Total  Aphasia,  321 

tional  compensation  must  also  have  been  gradually  brought 
about  through  the  further  development  of  the  correspond- 
ing centres  in  the  opposite  hemisphere."  The  constancy 
of  the  speech  defects  during  a  long  scries  of  years  and  the 
very  exact  way  in  which  the  original  defects  were  main- 
tained after  some  of  the  functional  activity  of  the  lost 
parts  had  been  transferred  to  the  opposite  hemisphere,  the 
writer  asserts,  are  worthy  of  attention. 

Appreciating  the  great  disadvantage  that  one  is  at  in 
endeavoring  to  put  interpretation  upon  a  case  from  a  very 
scant  report  of  the  leading  symptoms,  I  hesitate  to  do  more 
than  to  mention  this  case,  which  I  believe  will  become  an 
important  one  in  the  annals  of  aphasia  when  it  is  prop- 
erly published  (so  far  it  has  only  been  reported  to  a  medi- 
cal society).  Nevertheless,  it  seems  that  a  very  different 
interpretation  can  be  put  upon  some  of  the  conditions  than 
that  mentioned  by  Bastian.  In  the  first  place,  he  says 
there  was  no  word  blindness,  but  the  fact  that  the  patient 
had  inability  to  write  from  dictation  (although  he  fully  un- 
derstood words),  the  fact  that  he  could  not  read  aloud,  and 
the  fact  that  he  could  not  name  objects  at  sight  seem  to 
me  to  indicate  that  he  had  loss  of  the  visual  images  of 
words.  If  he  could  repeat  words  that  he  heard,  there  is 
no  other  lesion  that  will  explain  inability  to  read  aloud 
except  loss  of  the  visual  memories  of  words  and  naturally 
the  inability  to  invoke  such  memories  from  seeing  a  word. 
The  fact  that  he  could  utter  words  voluntarily  and  that  he 
could  repeat  words  after  they  were  said  to  him  shows  that 
the  auditory  images  were  capable  of  being  aroused,  and 
that  they  in  turn  were  able  to  react  upon  and  evoke  the 
articulatory  images;  otherwise  the  patient  would  not  have 


322  The  Faculty  of  Speech, 

been  able  to  say  a  word.  But  the  most  convincing  feature 
in  leading  us  to  the  assumption  that  the  patient  had  loss 
of  visual  memories  that  are  stored  up  in  the  angular  gyrus 
of  the.  left  side  is  his  total  inability  to  write.  Dejerine 
has  shown  that  spontaneous  writing  is  the  result  of  arous- 
ing the  visual  images  here  stored  and  the  copying  of  them 
by  the  motor  apparatus  that  holds  the  pen,  while  writing 
from  dictation  is  accomplished  in  exactly  the  same  way,  save 
that  the  visual  images  are  evoked  in  this  instance  through 
the  auditory.  Furthermore,  this  patient  retained  the 
ability  to  copy,  a  possession  which  shows  that  the  visual 
centre  that  reflects  words,  viz.,  the  visual  centre  in  the 
occipital  lobe  around  the  calcarine  fissure,  was  intact ;  the 
patient  saw  the  letter,  the  word,  or  the  design,  and  copied 
just  what  he  saw.  The  fact  that  he  was  unable  to  name 
objects  at  sight,  although  he  saw  them,  recognized  their 
uses,  etc.,  is  explained  in  exactly  the  same  way — inability 
of  the  patient  to  resuscitate  the  visual  memory  of  the 
name.  Although  willing  to  grant  that  the  uneducated 
right  hemisphere  became  in  eighteen  years  somewhat  edu- 
cated and  functioned  vicariously  for  the  part  of  the  speech 
area  that  was  destroyed  on  the  left  side,  I  am  not  inclined 
to  believe  that  this  vicarious  functioning  played  a  part  of 
such  paramount  importance  in  the  status  of  the  patient's 
speech  as  Bastian  would  have  us  believe  that  it  did.  It 
seems  to  me  the  interpretation  to  put  upon  this  case  is 
as  follows :  The  original  apoplectic  attack  was  due  to  a 
thrombosis  of  the  artery  of  the  fissure  of  Sylvius,  the 
direct  continuation  of  the  internal  carotid.  The  imme- 
diate result  was  a  partial  hemiplegia  of  a  cortical  nature, 
due  to  the  deprivation  of  blood  from  the  cortical  branches 


Total  Aphasia.  323 

of  the  middle  cerebral  artery  going  to  the  Rolandic  region ; 
a  partial  hemiansesthesia,  which  is  to  be  explained  by  the 
fact  that  the  middle  cerebral  artery  supplies  in  part  the 
posterior  limb  of  the  internal  capsule.  The  thrombus  in 
the  Sylvian  artery  caused  defective  activity  or  complete 
overthrow  of  functions  in  all  the  speech  centres,  and  until 
I  hear  to  the  contrary  I  am  prepared  to  believe  that  in  this 
patient,  before  he  came  under  Bastian's  care,  there  were 
some  word  deafness,  latent  or  manifest,  loss  of  capacity  to 
read  mentally,  and  much  more  extensive  aphemia  than  there 
was  three  months  after  the  accident.  After  the  substance 
occluding  the  calibre  of  the  vessel  was  removed,  or  partly 
removed,  some  of  the  speech  centres  (let  us  say  the  audi- 
tory, for  the  temporal  lobes  are  less  dependent  upon  the 
integrity  of  the  middle  cerebral  than  is  the  parietal),  the 
area  in  which  are  stored  auditory  images,  nearly  recovered 
itself,  and  there  were  no  gross  accompaniments  of  word 
deafness,  but  the  loss  of  visual  memories  remained  in  part 
to  the  end  as  did  the  loss  of  articulatory  images.  The 
successive  attacks  of  thrombosis  expended  themselves  in 
causing  softening  and  pseudo-cystic  formation  in  the  area 
from  which  blood  had  been  deprived  by  the  original 
thrombus. 

Thus  it  seems  to  me  that  this  is  a  good  example  of 
complex  aphasia,  in  which  the  symptoms,  although  per- 
haps very  nearly  indicative  of  complete  aphasia,  or  total 
aphasia,  clear  up  in  one  or  more  modalities  of  speech  as 
time  elapses. 


CHAPTER    VIII. 
DIAGNOSIS  OF  APHASIA. 

To  unravel  the  intricacies  of  aphasia  is  at  no  time  an 
easy  task,  but  it  can  be  made  immeasurably  more  difficult 
than  it  is  in  reality  by  approaching  the  examination  of  a 
case,  and  the  analysis  of  the  findings,  in  an  improper  or 
unmethodical  way.  Therefore,  the  first  step  in  attempt- 
ing the  diagnosis  is  a  simple  method  of  eliciting  and  asso- 
ciating the  different  symptomatic  constituents. 

One  who  takes  up  the  examination  of  a  patient  with 
aphasia  should  keep  in  mind  that  which  has  been  said  pre- 
viously concerning  the  constitution  of  the  speech  faculty 
— that  it  consists  of  two  parts,  the  receptive  and  the  emis- 
sive, and  that  either  of  these  two  parts  may  manifest  the 
predominance  of  the  aphasic  symptoms,  but  that  in  true 
aphasia,  that  is,  aphasia  dependent  upon  lesion  of  the 
speech  centres,  neither  can  be  the  sole  medium  of  mani- 
festation of  the  speech  defects.  It  should  further  be  re- 
membered that  emissive  speech  is  manifest  by  articula- 
tion, by  writing,  and  by  pantomime,  and  that  integrity  of 
the  receptive  side  of  language  is  commensurate  with  the 
interpretation  of  visual  and  auditory  stimuli. 

It  should  not  be  forgotten  that  the  attitude,  the  de- 
meanor, the  conduct,  of  the  patient  may  be  of  the  greatest 
service  in  orienting  the  physician,  from  the  very  begin- 
ning of  the  examination.  Though  recognition  and  inter- 


Diagnosis  of  Apkasia.  325 

pretation  of  information  thus  obtained  is  usually  consid- 
ered aquale  of  clinical  insight,  it  is  one  of  the  cultivatable 
forms  of  this  desirable  qualification.  The  demeanor  and 
expression  of  one  with  auditory  aphasia  are  frequently  those 
of  a  person  who  has  lost  all  interest  in  his  surroundings, 
and  his  attitude  is  that  of  a  deaf  person  who  is  slightly  de- 
mented. The  same  is  true,  though  to  a  lesser  degree,  for 
the  patient  with  visual  aphasia.  But  the  latter  is  more  fre- 
quently of  the  restless,  active  kind,  such  as  the  case  on  page 
265,  who  was  so  continuously  moving  and  shifting  that  she 
gave  the  impression  of  one  on  the  verge  of  acute  mania. 
Moreover,  patients  who  have  this  form  of  aphasia  are  often 
garrulous,  and  on  the  slightest  provocation,  or  without 
provocation,  emit  a  string  of  articulate  or  gibberish  sounds 
that  convey  no  meaning  to  those  about  them.  This  is  es- 
pecially true  of  cases  of  not  very  protracted  duration. 
Patients  with  cortical  motor  aphasia  and  with  subcortical 
motor  aphasia,  on  the  other  hand,  present  a  very  different 
aspect.  They  are  often  absolutely  silent  but  watchful, 
and  the  intensity  with  which  they  hold  every  move  of  the 
persons  surrounding  them  is  often  very  striking.  This  is 
well  shown  in  the  case  of  John  Masterson  (Case  No.  2). 
His  wife  repeatedly  said  that  the  feature  of  his  progres- 
sive recovery  that  impressed  itself  on  her  memory  more 
than  anything  else  was  the  assiduity  with  which  he 
watched  her  every  movement.  This  intentness  of  obser- 
vation is  particularly  to  be  marked  in  cases  of  subcortical 
motor  aphasia  in  which  the  patient  is  absolutely  speech- 
less yet  capable  of  the  fullest  understanding  of  all  that 
goes  on  about  him  and  within  his  hearing  and  vision. 
If  these  facts  be  kept  in  mind,  the  difficulties  encoun- 


326  The  Faculty  of  SpeecJi. 

tered  by  the  beginner  in  examining  a  patient  with  aphasia 
will  be  reduced  and  the  chances  of  reaching  warrantable 
and  legitimate  conclusions  as  the  result  of  the  examination 
will  be  greatly  increased.  Before  a  case  can  be  recorded 
in  such  a  way  that  the  symptomatic  findings  can  be  used 
legitimately  in  establishing,  or  demonstrating,  certain 
claims,  it  is  necessary  that  the  examination  be  conducted 
in  a  manner  that  searches  every  centre  which  must  func- 
tionate for  the  production  of  normal  speech  as  well  as 
their  connections.  To  do  this  it  should  be  systematic, 
but  it  need  not  be  done  in  conformation  to  any  special 
formula  or  according  to  any  hard-and-fast  system.  A 
number  of  schemes  have  been  devised  to  facilitate  the  ex- 
amination of  aphasic  patients,  but  I  have  found  the  follow- 
ing simple  plan  most  serviceable :  After  securing  a  gen- 
eral history  of  the  patient's  life  and  of  his  previous  illness 
from  some  member  of  the  family,  and  in  this  way  getting 
information  of  the  character  of  the  disease  of  which  the 
aphasia  is  a  symptom,  the  patient's  ability  to  express 
ideas,  to  receive  and  interpret  information  should  be  in- 
quired into.  The  mental  processes  apart  from  the  mani- 
festation of  mental  states  and  the  capacity  for  the  re- 
ception of  sensory  stimuli  should  then  be  examined. 
Although  a  number  of  these  may  be  determined  simulta- 
neously, it  is  best  to  take  each  one  separately. 

In  approaching  a  patient  with  aphasia  it  is  natural  that 
the  endeavor  be  made  to  elicit  information  by  speaking 
to  him.  It  becomes  necessary,  therefore,  to  determine  if 
the  patient  takes  note  of  what  is  said  to  him  orally,  and, 
secondly,  if  he  understands  what  is  said.  In  other  words, 
does  spoken  speech  awaken  in  his  auditory  centre  corre- 


Diagnosis  of  Aphasia.  327 

spending  memories  ?  This  can  be  done  ordinarily  by  ask- 
ing some  simple  question,  such  as,  "  How  long  have  you 
been  sick?"  or  by  addressing  to  him  some  simple  com- 
mand, such  as,  "Give  me  your  hand."  Care  must  be 
taken  not  to  employ  too  conventional  questions  or  com- 
mands, such  as,  "What  is  your  name?"  "Put  out  the 
tongue,"  etc.  The  patient  may  have  lost  the  auditory 
apperceptive  faculty  and  still,  oftentimes,  make  reasonable 
reply  to  such  questions,  merely  from  association  or  habit. 
Naturally  the  patient  should  get  no  information  of  what 
is  being  asked .  through  any  other  avenues  than  those  of 
hearing.  Such  patients  are  quick  to  grasp,  particularly 
if  they  have  been  aphasic  for  some  time,  the  significance 
of  even  slight  emotional  expression  or  pantomime  on  the 
part  of  the  interlocutor.  If  the  patient  does  not  reply  to 
such  questions  or  commands,  there  may  be  trouble  with 
the  receptive  or  with  the  emissive  speech  faculties.  If 
he  is  word  deaf,  that  is,  if  the  trouble  is  one  that  prevents 
the  sound  of  the  word  from  reaching  the  centre  in  which 
the  memories  of  previous  word  sounds  are  stored  up,  the 
patient  will  not  endeavor  to  respond  byword  or  act,  though 
in  some  instances  he  does  so.  Nor  will  the  face  show  the 
slightest  response  or  indication  of  comprehension.  If  he 
does  respond  the  diagnostic  feature  is  that  his  answer, 
even  though  it  be  made  up  of  articulate  words,  has  no  per- 
tinency or  bearing  on  the  question.  If  the  patient  is  not 
word  deaf,  he  will  make  some  movement,  be  it  of  the  head, 
hand,  or  features,  to  indicate  that  though  he  understands 
he  cannot  reply.  Generally  this  gesture  is  very  signifi- 
cant. It  consists  of  a  despairing  expression  of  the  coun- 
tenance and  a  touching  of  the  lips  or  the  throat  with  the 


328  The  Faculty  of  Speech. 

fingers.  Oftentimes  the  question  can  be  decided  very 
quickly,  if  there  remains  some  doubt  even  yet,  by  asking 
some  absurd  or  ludicrous  question,  and  noting  how  the 
patient  receives  it.  If,  in  reply  to  the  question,  "  Are 
you  one  hundred  years  old?"  he  solemnly  says,  "Yes,"  or 
if  he  does  not  see  the  ludicrousness  of  a  request  to  turn  a 
somersault  when  he  is  so  obviously  paralyzed,  it  is  rather 
convincing  proof  that  such  speeches  do  not  awaken  the 
proper  responses  in  his  mind ;  and  if  there  be  no  demen- 
tia it  is  suggestive  evidence  that  the  patient  is  word  deaf, 
and  the  examination  should  then  proceed  from  that  stand- 
point. Although  other  of  the  speech  centres  may  be 
simultaneously  disorganized,  the  symptoms  attributable  to 
the  first  one  will  dominate  the  character  of  the  speech 
defect.  If  the  examination  so  far  seems  to  suggest  the 
existence  of  word  deafness  as  the  leading  feature  of  the 
sensory  aphasia,  it  should  then  be  determined  to  what 
degree  of  completeness  this  exists,  and  the  extent  and 
kind  of  disturbance  that  it  causes  in  the  externalization  of 
language.  The  amount  of  diminution  of  the  patient's 
vocabulary,  the  degree  of  inappropriate  usage  of  words, 
the  imperfections  of  sequence  and  rhythm,  should  all  be 
noted.  The  patient  should  be  tested  for  his  power  of 
recognition  of  simple  words,  short  sentences,  and  long 
sentences.  It  has  already  been  noted  that,  perhaps,  he 
may  react  to  conventional  questions,  such  as,  "  Put  out 
the  tongue,"  etc.  Uncommon  requests,  such  as,  "  Touch 
the  nose  with  the  tip  of  the  index  finger,"  or,  "  Stand  on 
the  chair,"  should  be  made.  The  ability  of  the  patient  to 
interpret  sounds  should  then  be  noted.  Do  sounds  evoke 
previous  memories  of  similar  sounds  and  do  they  incite 


Diagnosis  of  Aphasia.  329 

the  auditory  centre  to  revive  the  name  of  the  object  from 
which  such  sounds  proceed  ?  When  a  bell  is  sounded,  or 
a  watch  is  held  behind  the  ear  and  apart  from  the  stimula- 
tion of  any  perceptual  avenue  other  than  hearing,  can  the 
patient  say,  "Bell"  or  "Watch"?  Finally,  the  existence 
of  any  disturbance  of  bone  or  aerial  conductivity  should 
be  demonstrated  or  excluded. 

If  word  deafness  can  be  excluded,  and  the  patient  still 
makes  no  reply,  that  is,  if  he  remains  completely  speech- 
less, the  examination  should  be  to  determine  whether  or 
not  internal  language  is  defective,  for  it  must  be  readily 
seen  that  the  question  has  then  narrowed  itself  to  a  deter- 
mination of  whether  or  not  the  aphasia  is  cortical  motor 
(kinaesthetic  word-image)  aphasia,  or  whether  it  is  sub- 
cortical  motor  aphasia.  In  other  words,  is  the  inability  to 
speak  due  to  a  lesion  of  the  storehouse  of  kinaesthetic 
memories  of  articulated  words,  Broca's  area,  or  is  it  due 
to  a  lesion  of  the  neurons  that  conduct  the  motor  word 
impulses  from  the  Rolandic  area  to  the  parts  that  exter- 
nalize the  word  ?  The  essential  thing  then  is  to  determine 
if  the  patient  is  in  the  full  possession  of  internal  lan- 
guage! If  internal  language  in  any  of  its  components  is 
disordered,  then  the  patient  has  true  cortical  motor  aphasia. 
If,  on  the  other  hand,  there  be  no  such  disturbance,  the 
lesion  is  elsewhere  than  in  the  zone  of  language.  In 
some  patients  the  differentiation  will  be  an  easy  one. 
They  will  show,  as  did  Case  No.  I,  that  they  have  the 
proper  idea  of  words  and  that  they  can  evocate  them 
promptly,  by  the  ease  and  rapidity  with  which  they  write, 
or  by  the  exquisiteness  of  pantomime,  as  did  the  patient 
just  referred  to.  On  the  other  hand,  however,  the  task  is 


330  The  Faculty  of  Speech. 

oftentimes  an  extremely  difficult  one.  It  is  particularly  so 
because  the  test  to  determine  if  the  legitimate  idea  of  words 
can  be  evoked  in  the  internal  language,  the  test  of  Proust 
and  of  Lichtheim,  is  not  one  of  universal  application,  be- 
cause in  the  first  place  many  of  our  hospital  and  dispensary 
patients  are  not  of  sufficient  scholarship  to  know  anything 
of  syllables,  or  of  counting  the  number  of  letters  forming 
them,  and  word  construction  is  an  exercise  that  has  never 
been  indulged  in.  In  the  second  place,  there  is  very  often 
associated  with  aphasia,  and  a  concomitant  of  the  disease 
giving  rise  to  the  latter,  a  degree  of  deficiency  in  the 
associative  faculties  that  amounts  to  a  slight  degree  of 
dementia.  In  such  patients  it  is  oftentimes  extremely 
difficult  to  make  them  understand  just  what  is  meant  by 
telling  them  to  press  the  physician's  hand  as  many  times 
as  there  are  syllables  in  the  word  Constantinople,  or  some 
other  equally  resonant  and  polysyllabic  word.  Nor  is  the 
substitute  suggested  by  Dejerine,  of  asking  the  patient  to 
make  voluntary  expiratory  efforts  as  many  times  as  there 
are  syllables  or  letters  in  a  word  more  applicable.  But 
even  when  we  cannot  get  the  patient  to  respond  to  these 
tests,  there  is  a  general  atmosphere  about  the  patient  with 
subcortical  motor  aphasia  that  one  cannot  be  long  in  with- 
out recognizing  that  the  patient  is  in  full  possession  of 
his  intellect  and  internal  speech.  The  only  shortcoming 
of  the  subcortical  motor  aphasic  is  inability  to  articulate. 
He  understands  everything  that  is  said  to  him ;  he  inter- 
prets information  received  through  the  visual  sphere;  he 
is  capable  of  expressing  his  thoughts  fully,  facilely,  and 
correctly,  by  writing  and  by  pantomime,  or,  at  least,  he 
would  be  were  it  not  that  the  right  half  of  the  body  is 


Diagnosis  of  Aphasia.  331 

usually  paralyzed  and  he  is  obliged  to  portray  mental 
states  by  the  pantomimic  activity  of  the  left,  the  less 
dextrous  half  of  the  body. 

Physicians  oftentimes  find  some  difficulty  in  properly 
assigning  cases  of  cortical  motor  (articulatory  kinaesthetic) 
aphasia,  because  the  patient  is  still  able  to  articulate  some 
words.  I  have  often  been  made  aware  of  this  by  con- 
versation with  my  house  physicians,  who  work  apparently 
with  the  following  formula :  "  If  the  patient  can  think  of 
the  word  and  is  unable  to  say  it,  he  has  motor  aphasia; 
but  if  he  cannot  think  of  the  word,  though  he  is  able  to 
say  it,  then  he  has  sensory  aphasia. "  If  one  had  to  choose 
between  this  formula,  and  nothing  at  all,  it  might  be  well 
to  choose  the  formula,  although  it  is  only  half  the  truth. 
If  it  be  kept  in  mind  that  the  patient  with  cortical  motor 
aphasia  (articulatory  kinaesthetic)  need  not  be  absolutely 
deprived  of  the  power  to  articulate  words ;  that  he  fre- 
quently retains  the  ability  to  say  one  or  several  words, 
which  he  uses  at  all  times  and  under  all  conditions,  perti- 
nent and  impertinent  alike ;  and  that  frequently  these 
words  take  the  form  of  recurring  utterances ;  that  there  is 
always  agraphia,  which  may  be  very  evident  or  which  may 
be  difficult  to  bring  out  because  the  patient  pleads  paraly- 
sis of  the  right  hand  as  an  excuse  for  not  making  an  effort 
to  write ;  that  the  agraphia  is  usually  proportionate  to  the 
aphasia ;  that  it  is  manifest  in  voluntary  writing  and  in 
writing  from  dictation,  but  not  in  writing  from  copy ;  and 
that  the  patient  in  copying  copies  print  in  script  and 
script  in  script,  showing  that  the  copying  is  not  a  mechani- 
cal but  an  intellectual  act ;  and  that  there  is  defective  in- 
ternal speech,  as  shown  by  the  test  of  Proust  and  Licht- 


332  The  Faculty  of  Speec/i. 

heim  —  then  the  diagnosis  of  articulatory  kinaesthetic 
aphasia  will  not  be  a  difficult  matter. 

After  voluntary  speech  has  been  satisfactorily  exam- 
ined, tests  should  be  made  to  determine  the  patient's 
capacity  to  repeat.  There  is  inability  to  repeat  in  both 
sensory  and  motor  aphasia,  and  if  word  deafness  has  been 
excluded  there  will  be  no  difficulty  in  interpreting  this  in- 
ability which  is  co-existent  with  loss  of  voluntary  speech 
in  articulatory  kinaesthetic  aphasia. 

Particular  attention  should  be  given,  in  every  case  of 
aphasia  in  which  the  symptoms  point  to  destruction  of 
Broca's  area,  to  the  faculty  of  writing.  Following  De- 
jerine,  it  has  been  maintained,  and  I  venture  to  hope  con- 
sistently, that  lesion  of  this  area  causes  agraphia.  Re- 
cently Bastian  has  reiterated  the  statement  that  the 
agraphia  that  sometimes  accompanies  articulatory  kinaes- 
thetic aphasia  is  not  dependent  upon  lesion  in  Broca's 
area  which  prevents  the  patient  from  getting  the  correct 
notion  of  the  word.  He  contends  that  it  is  an  occasional 
phenomenon  only,  and  when  it  occurs  it  is  due  (like 
alexia)  to  temporary  or  more  or  less  permanent  disable- 
ment of  the  visual  centre.  I  readily  admit  that  in  some 
instances  this  does  occur,  but  this  in  no  way  invalidates 
the  explanation  of  the  occurrence  of  agraphia,  which,  I 
believe,  occurred  in  every  case  of  cortical  motor  aphasia 
that  has  been  given.  The  fact  that  such  contradictory 
beliefs  are  held  as  to  the  occurrence  of  agraphia  with 
motor  aphasia  demands  the  very  careful  examination  of 
such  cases  in  the  future.  - 

Of  course,  when  a  patient  who  has  had  articulatory  kin- 
aesthetic  aphasia  has  partially  recovered  and  has  regained 


Diagnosis  of  Aphasia.  333 

quite  an  extensive  vocabulary,  it  will  require  care  and  re- 
peated examinations  satisfactorily  to  establish  the  diag- 
nosis. The  one  suggestion  that  I  have  to  make  in  such 
cases  is  that  there  will  always  be  found  some  degree  of 
every  one  of  the  symptoms  enumerated  as  occurring  with 
this  form  of  aphasia,  if  sufficiently  careful  and  patient 
search  be  made  for  them,  and  if  the  physician  is  trained 
to  recognize  these  slight  defects  they  are  of  great  service 
in  orienting  him. 

After  having  tested  the  patient's  capacity  to  perceive 
and  interpret  words  through  the  auditory  apparatus,  he 
should  be  examined  with  the  view  of  determining  if  there 
is  any  disability  of  acquiring  and  interpreting  information 
through  the  visual  apparatus.  To  do  this  requires  patience 
and  circumspection.  In  the  first  place  it  should  be  estab- 
lished that  the  patient  has  no  trouble  with  the  peripheral 
visual  apparatus.  This  can  be  done  by  an  ophthalmo- 
scopic  examination.  Tests  should  then  be  made  to  deter- 
mine the  existence  of  hemianopsia.  This  is  not  an  easy 
matter  to  do  if  the  patient  is  aphemic  or  if  he  has  word 
deafness ;  in  fact,  it  is  extremely  difficult  to  do  satisfac- 
torily. With  a  patient  who  can  understand  what  is  said 
to  him  and  who  can  indicate  when  he  perceives  the  en- 
trance of  an  object  into  the  visual  field,  who  can  tell  when 
the  indicator  of  a  perimeter  passes  beyond  the  range  of 
vision,  testing  for  hemianopsia  is  a  very  simple  matter. 
If  the  patient  is  word  deaf  and  if  he  has  visual  blindness, 
which  of  course  he  is  apt  to  have  if  he  has  hemianopsia, 
one  finds  himself  unable  to  convey  to  the  patient  by  writ- 
ten or  spoken  word  that  which  he  wishes  him  to  do  or  to 
observe.  In  such  cases  one  must  content  himself  with  the 


334  The  Faculty  of  Speech. 

information  that  is  to  be  derived  from  forcibly  and  sud- 
denly thrusting  some  object  into  the  visual  fields,  from  the 
right  side  (for  right-handed  patients  invariably  have  right 
lateral  homonymous  hemianopsia  when  they  have  any),  and 
taking  note  whether  or  not  the  patient  blinks,  as  he  should 
do  if  the  object  be  perceived.  If  he  does  not  it  is  rather 
certain  that  he  has  hemianopsia.  Each  eye  should  be 
examined  separately  and  the  findings  noted  on  a  chart. 
The  form  of  hemianopsia  that  may  be  found  will  be  read- 
ily interpreted  if  one  has  clearly  in  mind  the  course  of  the 
optic  nerve  and  the  tract  to  the  cortex  (see  Fig.  6).  A 
destructive  lesion  of  the  cortex  in  the  vicinity  of  one  cal- 
carine  fissure,  or  of  all  the  optic  fibres  leading  to  it,  the 
radiations  of  Gratiolet,  produces  blindness  on  the  opposite 
sides  of  the  visual  field.  If  the  left  one  is  destroyed  there 
will  be  right  hemianopsia,  and  as  the  hemianopsia  is  on 
relatively  the  same  sides  of  the  visual  field,  that  is  the 
right  temporal  and  the  right  nasal,  the  hemianopsia  is 
called  homonymous.  If  the  right  cuneus  is  destroyed 
just  the  same  condition  will  prevail,  only  it  will  be  mani- 
fested on  the  other  side ;  and  if  both  cunei  are  destroyed 
there  will  be  true  cortical  blindness.  If  these  facts  be 
kept  in  mind  there  can  be  no  difficulty  in  properly  inter- 
preting the  occurrence  of  hemianopsia.  If  there  is  de- 
struction of  the  cortex  in  the  vicinity  of  the  calcarine 
fissure,  that  is,  destruction  of  a  half-vision  centre,  there 
will  be  lateral  homonymous  hemianopsia,  but  not  word 
blindness,  as  the  higher  visual  centre  is  still  in  intact 
connection  with  the  half- vision  centre  of  the  other  cuneus. 
If  there  is  lesion  of  the  bands  of  Gratiolet  connecting  both 
half -vision  centres  with  the  primary  visual  centre  and  one 


Diagnosis  of  Aphasia.  335 

cuneus  with  homonymous  parts  of  both  visual  fields,  then 
there  will  be  hemianopsia  and  word  blindness,  complete 
alexia,  merely  because  the  patient  cannot  send  impulses 
coming  in  from  both  half -vision  centres  to  the  angular  gyrus 
where  they  are  interpreted,  although  the  latter  is  intact 
and  shows  this  intactness  by  the  undefectiveness  of  inter- 
nal language  and  the  ability  to  write  spontaneously  and 
from  dictation.  Such  a  patient  copies  mechanically,  print 
in  print,  script  in  script,  as  one  traces  a  drawing.  This, 
and  one  other  fragment  of  knowledge  concerning  hemi- 
anopsia, are  all  that  is  necessary  properly  to  interpret  its 
occurrence.  Sometimes  a  lesion  that  destroys  the  angular 
gyrus  extends  sufficiently  deep  to  sever  the  optic  radia- 
tions of  Gratiolet,  which  are  immediately  subjacent  on 
their  way  to  the  occipital  lobes;  in  such  cases  there  will 
be  true  word  blindness  with  all  its  entailment  of  disturb- 
ance of  internal  language,  disturbance  of  intellection, 
agraphia,  etc.,  plus  hemianopsia,  but  the  latter  symptom  is 
merely  an  accident,  a  superadded  phenomenon,  and  it  never 
occurs  with  destruction  of  the  angular  gyrus,  except  in 
some  such  way  as  I  have  indicated. 

In  testing  the  patient  to  determine  the  integrity  of  the 
visual  mechanism  one  may  begin  by  showing  him  familiar 
objects.  If  he  does  not  recognize  them,  or  show  by  act 
or  deed  that  he  comprehends  their  use  or  purpose,  if  he 
looks  upon  them  as  does  one  who  sees  them  for  the  first 
time,  then  he  has  object  aphasia  and  the  lesion  is  of  the 
occipital  cortex.  Such  an  individual  may  obtain  informa- 
tion through  the  medium  of  other  special  senses,  such  as 
the  tactile,  gustatory,  etc.,  that  will  enable  him  to  recog- 
nize the  object,  the  person,  or  the  thing.  If  he  is  shown 


336  The  Faculty  of  Speech. 

familiar  objects  and  he  recognizes  them,  knows  what  they 
are  for,  but  cannot  name  them,  then  he  may  have  either 
an  interruption  in  the  pathway  leading  to  the  higher 
visual  centre  in  the  angular  gyrus,  or  there  may  be  lesion 
of  the  angular  gyrus  itself.  If  it  be  of  the  former,  inter- 
nal language*  will  be  preserved  and  spontaneous  speech 
may  be  intact,  although  there  is  usually  some  paraphasia 
and  possibly  jargonaphasia,  and  this  preservation  is  shown 
most  conclusively  by  the  retention  of  ability  to  write. 
He  may  write  easily  and  moderately  well,  not  only  volun- 
tarily but  from  dictation,  but  the  patient  is  unable  to 
read  what  he  writes.  If  it  be  of  the  latter  and  complete, 
the  patient  will  be  absolutely  agraphic.  This  agraphia  is 
to  be  considered  a  part  of  the  disorder  of  internal  lan- 
guage, loss  of  the  visual  image,  the  visual  idea  of  the 
word.  There  is  inability  to  arouse  the  visual  image  of 
the  word.  In  such  a  case,  as  arousal  must  precede  the 
transmission  to  the  part  of  the  Rolandic  cortex  that  in- 
nervates the  member  holding  the  pen,  there  is  complete 
agraphia.  There  is  no  more  strikingly  illustrative  case  of 
this  on  record  than  one  communicated  to  the  Royal  Medi- 
cal and  Chirurgical  Society  in  1872,  which  was  one  of  the 
first,  if  not  the  first,  in  which  subcortical  word  blindness 
was  the  striking  symptom.  Although  this  case  was  used 
by  Broadbent  then,  and  is  still  to-day,  to  bear  evidence  in 
favor  of  a  naming  centre,  it  must  be  apparent  to  him 
who  interprets  the  genesis  of  speech  in  the  light  of  our 
present  knowledge  that  in  reality  it  is  a  most  recalcitrant 
witness  in  behalf  of  Broadbent's  claim.  The  history  of 
the  case,  if  space  permitted  us  to  quote  it  in  detail,  would 
be  very  instructive  to  show  the  typical  picture  of  subcor- 


Diagnosis  of  Aphasia.  337 

tical  sensory  aphasia.  "  The  patient  after  an  acute  cere- 
bral attack  (?)  showed  absolute  inability  to  read  printed 
or  written  words  (except  his  name),  while  he  wrote  cor- 
rectly from  dictation  and  spontaneously."  There  was  in- 
ability to  recall  the  name  of  the  most  familiar  object  pre- 
sented to  his  sight,  while  he  conversed  intelligently, 
employing  an  extensive  and  varied  vocabulary,  making 
few  mistakes,  but  occasionally  forgetting  names  of  streets, 
persons,  and  objects.  There  is  no  note  of  whether  or  not 
hemianopsia  existed,  but  it  may  be  taken  for  granted,  I 
think,  that  it  did,  for  in  every  published  case,  without  ex- 
ception, in  which  this  condition  was  examined  for  it  has 
been  found.  In  regard  to  Broadbent's  statement  that  it 
bears  evidence  in  favor  of  a  naming  centre,  it  need  only  be 
said  that  the  case  shows  that  there  was  a  lesion  that  severed 
the  visual  percipient  centre  from  the  visual  interpreting 
centre,  and  if  he  prefers  to  call  the  latter  a  naming  centre 
no  adequate  reason  has  ever  been  offered  why  he  does  so. 
One  then  proceeds  to  examine  to  see  if  the  patient  has 
word  blindness;  that  is,  can  the  patient  read  (i)  print,  (2) 
script,  (3)  figures  and  other  forms  of  notation.  I  have 
already  described  the  significance  of  inability  to  do  all  or 
one  of  these.  It  can  need  no  repetition  to  show  that  in- 
ability to  read  is  not  of  itself  an  important  localizing 
symptom ;  it  may  be  produced  by  lesion  in  many  parts  of 
the  optic  projection  and  of  the  parts  that  the  optic  projec- 
tion goes  to.  It  is  the  association  of  the  inability  to 
read  that  facilitates  localizing  the  lesion.  If,  for  instance, 
a  person's  primary  visual  centres  are  intact,  he  sees  the 
written  or  printed  word,  the  figure  or  symbol,  in  all  its 
details  ;  it  merely  has  no  significance  for  him.  This  bears 


338  The  Faculty  of  Speech. 

testimony  that  the  lesion  is  centralward  to  the  primary 
visual  area.  He  can  decide  at  once  whether  it  be  far 
enough  centralward  to  be  in  the  angular  gyrus,  the  higher 
visual  centre,  or  not,  by  determining  if  there  be  disturb- 
ance of  internal  language.  If  there  is  not  (and  as  a  mat- 
ter of  fact  one  may  say  if  there  be  no  agraphia  the  lesion 
is  not  in  the  zone  of  language),  then  the  word  blindness 
is  the  result  of  a  subcortical  lesion.  One  word  of  caution 
must  be  sounded  for  the  inexperienced  in  determining 
visual  blindness.  Some  patients  who  have  word  blind- 
ness, particularly  those  in  whom  the  symptom  is  depen- 
dent upon  lesion  of  the  higher  visual  centre,  on  being  asked 
to  read,  take  up  a  book  or  paper,  or  whatever  is  handed  to 
them,  and  essay  to  read  it  understandingly.  If  they  are 
made  to  read  it  aloud  it  will  quickly  be  seen  that  they 
cannot  read  a  word,  that  they  "  make  up,"  as  children  do, 
as  they  go  along.  Oftentimes  the  assurance  with  which 
they  take  hold  of  a  paper  or  letter  and  apparently  read  it 
deceives  even  an  experienced  examiner.  It  cannot  do  so, 
however,  if  the  physician  will  show  them  writing  or  print 
embodying  a  request  set  forth  in  such  a  way  that  cannot 
escape  their  recognition  if  they  read  it,  such  as  :  "  If  you 
are  able  to  read  this  then  put  your  left  hand  in  mine." 
Another  test  often  employed  is  for  the  physician  to  read 
aloud  the  last  lines  of  a  page  and  request  the  patient  to 
turn  the  page  at  the  proper  time.  Naturally,  he  is  unable 
to  do  so,  as  he  cannot  read,  although  if  he  is  not  at  all 
word  deaf,  that  is,  if  he  can  appreciate  the  quantity  and 

• 

amount  read,  he  may  very  closely  approximate  the  time 
when  he  should  turn. 

In  cases  of  complete  aphasia  the  examination  is  very 


Diagnosis  of  Aphasia.  339 

difficult  and  to  one  not  accustomed  to  such  a  task  it  seems 
very  unsatisfactory,  as  he  is  apparently  unable  to  communi- 
cate with  the  patient  or  receive  any  information  from  him. 
Oftentimes  it  is  thought  that  such  patients  have  not  re- 
covered consciousness  completely.  I  have  such  a  patient 
at  the  present  time  under  observation :  A  married  man, 
fifty-six  years  old,  of  good  habits,  was  seized  one  day  with 
a  feeling  of  numbness  and  beginning  powerlessness  in  the 
right  leg,  which  after  a  few  minutes  showed  itself  in  the 
right  upper  extremity.  In  less  than  a  quarter  of  an  hour 
he  became  unconscious  and  completely  hemiplegic.  There 
had  been  no  premonitory  symptoms  save  recurring  head- 
ache, which,  his  wife  now  recalls,  had  been  complained  of 
for  several  weeks  previous  to  the  apoplexy.  On  the  third 
day  after  the  attack  signs  of  returning  consciousness  began 
to  show  themselves,  and  at  the  end  of  a  week  there  was 
apparently  complete  restoration  of  consciousness.  The 
hemiplegia  continued  complete,  the  face  being  least 
severely  involved. 

The  following  notes  of  the  examination  show  the  com- 
pleteness of  the  aphasia  in  this  case  : 

What  is  your  name?  No  response;  looks  at  me 
blankly  and  staringly. 

Is  your  name ?  No  reply,  slight  shifting  or  rest- 
lessness of  the  patient. 

Are  you  seventy  years  old  ?     No  reply. 

Would  you  like  to  go  home  with  your  wife  ?  No  reply, 
no  interest. 

Then  these  same  questions  were  addressed  to  him  in 
writing  and  in  print,  but  he  took  no  more  heed  of  them 
when  endeavor  was  made  to  bring  them  to  his  notice  in 
this  way  than  when  they  were  spoken.  It  was  impossible 


34-O  The  Faculty  of  Speech. 

to  establish  with  any  degree  of  certainty  the  existence  of 
hemianopsia.  The  impression,  as  the  result  of  repeated 
and  careful  testing,  was  that  it  did  not  exist.  There  was 
apparently  no  object,  no  mind  blindness.  The  patient 
took  a  piece  of  candy  that  his  wife  brought,  carried  it  to 
the  mouth,  and  ate  it  with  apparent  relish.  When  given 
a  pencil  he  grasped  it  and  handled  it  in  a  familiar  way, 
likewise  a  watch,  a  key,  and  other  common  objects.  He 
recognized  members  of  his  family,  and  when  his  wife 
came  to  see  him  he  would  grasp  her  hand  and  carry  it  to 
his  lips.  He  would  try  to  detain  her  from  leaving,  and 
manifested  appreciation  of  visits. 

Persistent  efforts  to  get  him  to  write  a  word  are 
wasted.  He  grasps  the  pencil  as  if  he  were  about  to 
write,  but  instead  of  proceeding  to  form  a  letter  he 
scratches  the  paper,  just  as  an  infant  does  who  is  given  a 
pencil  for  the  first  time.  If  I  guide  his  left  hand  which 
holds  the  pencil  to  outline  his  name,  or  the  names  of 
familiar  objects,  and  then  show  them  to  him,  he  does  not 
understand  the  one  or  recognize  the  other.  If  I  guide 
his  hand  over  the  letters  of  a  word  to  trace  it,  he  may 
trace  the  next  word  alone,  but  he  does  it  mechanically  and 
takes  not  the  slightest  interest  in  it.  When  he  is  given  a 
number  of  bills  of  different  denominations,  it  is  impossible 
to  say  that  he  understands  the  difference  in  value  of  them, 
for  he  takes  with  the  same  readiness  a  twenty-dollar  bill 
and  a  two-dollar  bill.  He  does  not  utter  a  word  or  the 
semblance  of  a  word.  He  does  not  indulge  in  any  form 
of  pantomime  or  mimetic  action.  There  seems  to  be  ab- 
solutely no  way  of  communicating  information  to  him  or 
of  receiving  wishes  or  desires  from  him.  In  other  words, 
he  has  total  aphasia.  In  another  connection,  it  may  be 
recalled,  it  was  stated  that  sometimes  such  cases  of 
aphasia  clear  up  on  one  side  of  language,  the  receptive  or 


Diagnosis  of  Aphasia.  341 

the  emissive,  and  the  residue  of  the  aphasic  symptom  com- 
plex constitutes  sensory  or  motor  aphasia. 

In  this  patient  it  would  seem  that  the  middle  cerebral 
artery  had  ruptured  and  that  the  speech  area  has  suffered 
so  severely  that  restitution  will  not  follow,  as  sufficient 
time  has  already  elapsed  to  have  it  show  itself  if  the 
vital  forces  were  sufficient  to  do  so.  The  fact  that  he 
has  an  advanced  degree  of  chronic  interstitial  nephritis, 
and  the  fact  that,  despite  most  careful  dietetic  and  vigor- 
ous medicinal  treatment,  he  is  continually  emaciating, 
augurs  ill  for  him. 

Sufficient  has  already  been  said  of  dyslexia  in  the  chap- 
ter on  "  Sensory  Aphasia"  to  make  reference  to  it  here,  as 
a  factor  in  diagnosis,  unnecessary.  I  am  disposed  only  to 
reiterate,  particularly  since  reading  the  first  of  Bastian's 
recent  lectures  on  problems  in  aphasia  and  other  speech 
defects,  which  appeared  after  this  monograph  was  written, 
the  necessity  of  the  most  painstaking  examination  to  re- 
veal latent  defects  of  internal  reading  in  every  case  of 
aphasia.  After  the  condition  of  the  functional  state  of 
the  different  speech  centres  and  the  immediate  conducting 
tracts  leading  to  and  away  from  them  have  been  inquired 
into,  and  a  general  survey  has  been  taken  of  the  patient, 
two  things  remain  to  be  clone ;  namely,  an  examination  of 
the  patient's  capacity  to  externalize  mental  contents  by 
pantomime  or  mimicry,  and  a  study  of  the  manifestations 
of  emotion  in  melody,  instrumental  music,  profanity,  in- 
terjections, and  gestures.  It  is  believed  that  sufficient 
has  already  been  said  of  these  to  make  reconsideration 
of  them  unnecessary. 

It  is  necessary  to  say  one  word  concerning  the  time  of 


342  The  Faculty  of  Speech. 

examination  of  patients  with  aphasia.  The  complexity  of 
symptoms  that  may  be  determined  one  or  two  weeks  after 
the  restoration  of  consciousness  following  the  apoplectic 
insult,  or  the  confusion  and  delirium  which  may  be  the 
introductory  symptoms  of  the  aphasia,  may  be  quite  dif- 
ferent from  that  found  when  the  examination  is  made  later. 
The  morbid  vascular  changes  that  go  on  secondarily  to  the 
lesion,  whatever  it  may  be,  will  subside  in  part  after  the 
acute  manifestations  of  the  disease  or  accident  have  disap- 
peared, and  if  they  have  not  been  of  sufficient  severity  to 
cause  destruction  of  the  parts  the  area  that  was  for  a  time 
obscured  will  again  functionate  with  more  or  less  integ- 
rity. It  is  well,  therefore,  to  compare  the  results  of  the 
clinical  status  made  early  with  those  made  after  the  symp- 
toms have  continued  for  a  time,  and  thus  to  establish  the 
permanent  degree  as  well  as  the  kind  of  aphasia. 


CHAPTER    IX. 
ETIOLOGY. 

BEFORE  enumerating  the  individual  organic  diseases  or 
functional  conditions  of  which  the  different  varieties  of 
aphasia  may  be  a  symptom,  I  wish  to  direct  attention  very 


FIG.  19.— Vascular  Supply  of  Cortex. 

briefly  to  the  boundaries  and  blood  supply  of  the  zone  of 
language,  which  contains  the  centres  of  auditory,  visual, 
and  articulatory  (kinaesthetic)  images.  The  locations  of 
these  centres  in  this  zone  of  language  are  now  definitely 
assigned.  Their  relative  position  on  the  surface  of  the 
brain  is  shown  in  Fig.  7,  page  99.  Their  boundaries 
and  interrelations  are  considered  in  Chapter  IV.,  "  Con- 
ception of  Aphasia." 


344 


The  Facility   of  Speech. 


A  comprehensive  knowledge  of  the  vascular  supply  to 
this  portion  of  the  brain  is  necessary  for  A  full  under- 
standing of  the  mode  of  development  and  the  lesions  of 
aphasia.  Such  knowledge  can  best  be  obtained  by  a  study 


FIG.  20.— Cortical  Blood-Vessels  of  Foetal  Brain. 

of  the  fresh  brain.  The  accompanying  illustration  (Fig. 
19),  taken  from  the  well-known  work  of  Duret,  will  convey 
an  idea  of  the  distribution  of  the  blood-vessels  to  the  exter- 
nal surface  of  the  brain.  It  shows  the  middle  cerebral 
artery,  which  supplies  the  side  of  the  cortex  in  all  its  ramifi- 
cations. It  will  be  seen  that  this  one  artery  supplies 
through  its  trunk,  its  principal  branch,  and  its  terminals 


Etiology.  345 

the  zone  of  language  and  the  three  centres  lying  therein. 
Fig.  20  shows  the  cortical  vessels  of  the  foetal  brain  par- 
ticularly in  their  relation  to  the  fossa  of  Sylvius.  When 
one  considers  the  importance  of  the  middle  cerebral  artery 
to  the  zone  of  language,  it  is  no  longer  surprising  that  we  do 
not  oftener  encounter  cases  of  aphasia  whose  symptoms  can 
be  interpreted  as  due  to  lesion  of  an  individual  centre. 
The  middle  cerebral  artery,  the  largest  and  most  important 
branch  of  the  internal  carotid,  in  fact,  the  continuation  of 
the  latter,  supplies  other  parts  than  the  zone  of  language, 
and  enumeration  of  these  parts  facilitates  interpretation  of 
the  accompanying  symptoms  in  many  cases  of  aphasia.  The 
antero-lateral  arteries  which  are  given  off  from  the  middle 
cerebral  immediately  after  leaving  the  carotid  artery  pass 
through  the  foramina  of  the  anterior  perforated  space  to 
the  base  of  the  corpus  striatum  and  form  the  most  impor- 
tant supply  of  that  region.  The  lenticular  branch  sup- 
plies the  inner  and  middle  segments  of  the  lenticular 
nucleus  and  the  internal  capsule.  The  lenticulo-striate 
arteries  supply  the  outer  segment  of  the  lenticular  nucleus 
and  external  capsule  and  the  caudate  nucleus,  and  the 
lenticular-optic  arteries  supply  the  outer  part  of  the  optic 
thalamus.  The  vessel  then  passes  to  the  cortex. 

The  cortical  branches  of  the  middle  cerebral  artery,  or 
the  Sylvian  artery,  the  continuation  of  the  main  trunk  of 
the  internal  carotid,  are  the  interior  external  frontal,  dis- 
tributed to  the  outer  part  of  the  orbital  surface  of  the 
hemisphere  and  adjacent  frontal  convolutions;  the  ascend- 
ing frontal,  distributed  to  the  convolution  of  the  same 
name  and  to  the  root  of  the  middle  frontal  convolution ; 
the  ascending  parietal  to  the  parietal  convolution  and  to 


346  The  Faculty  of  Speech. 

the  forepart  of  the  superior"  parietal  lobule;  and  the 
parieto-temporal,  which  runs  backward  in  the  posterior 
limb  of  the  fissure  of  Sylvius  and  ramifies  upward  over 
the  angular  gyrus  and  downward  over  the  superior  and 
upper  part  of  the  middle  temporal  convolution. 

Contrasting  the  distribution  of  this  artery  on  the  cortex 
with  the  relative  position  of  the  different  speech  centres, 
it  will  be  seen  that  a  lesion  of  the  trunk  at  its  entrance 
into  the  fossa  of  Sylvius,  and  particularly  a  lesion  of  the 
first  branch,  will  be  very  apt  to  destroy  Broca's  convo- 
lution, in  which  are  stored  the  kinaesthetic  memories 
of  articulation.  If  the  lesion  is  not  of  sufficient  sever- 
ity to  destroy  the  centre  it  may  materially  pervert  its 
functions,  and  this  perversion  may  be  transient  or  lasting. 
Simultaneously  with  the  occurrence  of  such  a  lesion  the 
integrity  of  the  circulation  in  the  posterior  parts  of  the 
vessel,  in  the  terminal  branches,  the  one  bending  up  over 
the  angular  gyrus  and  the  other  down  over  the  temporal 
convolution,  may  be  disturbed,  though  to  a  very  insignifi- 
cant degree  compared  with  the  disturbance  of  Broca's 
centre,  but  yet  sufficient  to  add  a  sensory  element  to  the 
aphasic  symptom  complex.  Thus,  in  the  beginning  of 
some  cases  of  aphasia,  the  symptoms  may  indicate  a  mixed 
form,  but  the  slight  sensory  or  motor  element,  as  the  case 
may  be,  may  disappear,  leaving  the  other  dominant  to  con- 
stitute the  form  of  aphasia.  It  is  not  in  place  here  to 
point  out  that  the  aphasic  symptoms  vary  not  alone  with 
the  seat  of  the  lesion,  but  with  the  intensity  of  the  lesion, 
the  rapidity  of  its  progress  and  development,  or,  in  other 
words,  with  its  nature.  This  may  be  inferred  from  what 
has  just  been  said. 


Etiology.  347 

With  the  exception  of  destruction  of  the  speech  areas 
that  are  the  result  of  injury  and  new  growth,  organic  dis- 
ease of  the  zone  of  language  is  almost  always  the  result  of 
vascular  lesion.  These  vascular  lesions  are  rupture  of 
the  blood-vessels  and  occlusion  of  their  calibres,  whether 
from  embolus  cr  thrombus,  and  the  consecutive  changes 
dependent  thereon.  The  lesions  of  the  blood-vessels  may, 
however,  be  due  to  inflammatory  conditions  of  the  vessels, 
but  even  then  it  is  not  at  all  improbable  that  the  pathogene- 
sis  of  the  lesion  is  the  direct  result  of  a  septic  or  infec- 
tious process  that  causes  infectious  emboli  and  thrombi. 
The  traumatic  conditions  that  may  produce  aphasia  are 
bullet  and  stab  wounds,  depressed  fractures  of  the  skull, 
and  injuries  producing  meningeal  hemorrhage. 

Etiologically,  aphasia  may  be  classified  into  organic  and 
dynamic.  The  principal  organic  forms  have  just  been 
enumerated.  Under  the  dynamic  forms  may  be  included 
those  in  which  no  organic  lesion  is  responsible  for  the 
development  of  aphasic  symptoms.  The  term  dynamic  is 
used  merely  as  a  convenience  in  preference  to  the  conven- 
tional "  functional."  The  dynamic  variety  includes  aphasia 
occurring  with  neuroses  and  psychoses  which  are  not  yet 
proven  to  be  dependent  upon  recognizable  brain  lesion,  of 
which  epilepsy,  neurasthenia,  and  hysteria  may  be  taken 
as  examples.  It  also  embraces  most  of  the  cases  of  aphasia 
occurring  with  toxihaemia,  such  as  uraemia,  diabetes,  and 
gout ;  although  aphasia  in  some  of  these  cases,  especially 
aphasia  occurring  with  uraemia,  is  often  dependent  upon 
organic  vascular  lesion  of  the  cerebral  blood-vessels. 
Aphasia  caused  by  the  vegetable  poisons,  santonin,  bella- 
donna, tobacco,  etc.,  is  almost  invariably  of  the  dynamic 


348  The  Facility  of  Speech. 

form.  The  aphasia  that  sometimes  occurs  in  individuals 
who  have  been  poisoned  by  lead,  copper,  etc.,  may  be  of 
the  dynamic  variety,  or  it  may  be  a  focal  manifestation  of 
the  encephalopathy  that  these  poisons  occasionally  cause. 
The  dynamic  aphasias  also  include  the  aphasic  speech 
disturbances  occurring  with  neuralgic  affections  of  a 
migrainous  order,  those  occurring  with  forms  of  insanity 
that  have  no  known  anatomical  basis,  and,  finally,  the 
comparatively  insignificant  number  which  are  attributed  to 
fright,  anger,  so-called  reflex  causes,  such  as  intestinal 
worms,  and  the  transitory  aphasias  from  loss  of  blood. 

Ordinary  etiological  factors,  such  as  age,  sex,  occupa- 
tion, etc.,  have  no  bearing  on  the  causation  of  aphasia, 
because  it  is  itself  a  symptom,  and  it  results  only  when 
the  diseases  of  which  it  is  a  symptom  occur  or  are  prone 
to  occur ;  but  as  aphasia  is  so  often  associated  with  cere- 
bral apoplexy,  and  as  cerebral  apoplexy  occurs  usually  in 
late  maturity  and  advanced  age,  it  follows  that  aphasia  is 
seen  oftener  in  people  beyond  fifty  years  of  age.  Never- 
theless, it  would  be  misleading  to  leave  this  statement 
unmodified,  for  the  reason  that  three  diseases  which  not 
infrequently  have  aphasia  as  a  symptom,  namely,  uraemia, 
acute  hemorrhagic  encephalitis,  and  tuberculous  menin- 
gitis, are  particularly  liable  to  occur  in  the  young.  More- 
over, aphasia  sometimes  develops  in  the  wake  of  the  infec- 
tious diseases,  typhoid,  diphtheria,  and  pertussis,  and,  as 
these  occur  more  frequently  in  youth  than  at  any  other 
time,  it  follows  that  the  aphasias  of  this  variety  will  be 
seen  oftenest  at  this  time  of  life. 

It  is  my  intention  to  enumerate  the  more  prominent 
diseases  of  which  aphasia  is  an  important  symptom,  and 


Etiology.  349 

to  dwell  upon  a  few  of  these  only.  In  addition  to  those 
already  mentioned,  it  may  be  said  that  aphasia  of  any  kind 
may  be  referable  to  some  such  disease  of  the  skull  as 
exostosis  and  bony  tumor;  in  short,  to  any  condition  of 
the  skull  bones  or  the  meninges,  such  as  pachymeningitis, 
that  produces  pressure  on  or  irritation  of  the  speech  area. 
It  is  an  occasional  symptom  of  thrombosis  of  the  dural 
sinuses,  particularly  thrombosis  of  the  lateral  sinuses. 

Aphasia  is  one  of  the  most  important  and  constant 
symptoms  of  acute  non-purulent  encephalitis.  A  case  re- 
cently reported  by  Leva1  is  a  good  illustrative  example. 
The  patient  had  pronounced  sensory  aphasia,  total 
alexia,  and  agraphia,  but  no  articulatory  aphasia.  At 
the  autopsy  there  was  found  diffuse  encephalitis,  with 
softening  in  the  first  and  second  insular  gyri  of  the  left 
hemisphere,  in  the  adjacent  convolutions  of  the  inferior 
hemispherical  convolutions,  and  some  disintegration  of 
the  first  temporal  gyrus  adjacent  to  the  insula.  In  the 
right  hemisphere  similar  areas  of  softening  were  found 
in  the  right  temporal  gyrus. 

Depending  upon  the  locality  of  the  abscess,  a  variety  of 
aphasia  is  frequently  an  important  symptom  of  purulent 
circumscribed  encephalitis,  and  especially  the  form  com- 
plicating purulent  disease  of  the  middle  ear.  In  fact,  in 
cases  of  brain  abscess  it  is  oftentimes  a  localizing  symp- 
tom of  most  exquisite  value.  This  is  well  illustrated  by 
a  case  recently  published  by  Zaufal : 2 

1  Leva  :  Virchow's  Archiv,  vol.  cxxxii.,  part  ii. 

5  Zaufal  and  Pick  :  "  Otitischer  Gehirnabscess  im  linken  Temporallap- 
pen,  optische  Aphasie,  Eroffnung  durch  Trepanation.  Heilung."  Prager 
med.  \\~ochenschr. ,  Xos.  5,  6,  8,  9,  1897. 


35<3  The  Facility  of  Speech. 

A  young  woman,  twenty-five  years  old,  complained  of 
headache,  pain  in  the  left  ear,  nausea,  and  vomiting. 
Eight  days  later  there  was  a  discharge  of  pus  from  the 
left  ear.  Examination  revealed  acute  suppuration  of  the 
middle  ear,  inequality  of  the  pupils,  progressive  stupor, 
and  vomiting.  Shortly  after  this,  the  patient  was  unable 
to  name  objects  shown  to  her,  although  she  knew  them 
well  and  could  describe  their  appearance ;  that  is,  there 
was  optic  aphasia,  pointing  to  a  lesion  severing  the  con- 
nections of  the  primary  visual  area  with  the  area  of  word 
memories;  in  other  words,  a  pure,  or  subcortical  visual 
aphasia.  The  lesion  was  localized  by  Pick,  and  an  opera- 
tion revealed  an  abscess  of  the  size  of  a  hen's  egg  in  the 
region  indicated,  namely,  in  the  left  second  and  third  tem- 
poral convolutions  far  back  and  in  the  white  substance. 
The  patient  made  a  complete  recovery.  In  this  case  it  is 
to  be  noted  that  there  was  no  hemianopsia,  which  showed 
that  the  primary  visual  area  around  the  calcarine  fissure, 
as  well  as  the  radiations  of  Gratiolet  were  not  affected. 

Another  most  instructive  instance  of  the  same  kind, 
but  in  which  the  outcome  was  not  so  gratifying,  is  that  of 
a  case  related  by  Lannois  and  Jaobulay.1  In  this  case 
there  were,  in  addition  to  symptoms  of  ear  disease  and 
brain  abscess,  alexia,  agraphia,  word  blindness,  right-side 
hemianopsia,  and  slight  facial  paralysis.  The  patient  was 
operated  on  but  no  pus  was  found.  A  second  operation  was 
made  three  weeks  later,  and  a  collection  of  pus  was  evac- 
uated. Eleven  days  later  the  patient  died,  and  on  autop- 
sical  examination  a  large  abscess  was  found  in  the  centre 
of  the  left  occipital  lobe.  There  were  also  a  number  of 
foci  of  diffuse  encephalitis,  some  of  them  purulent,  proba- 

1  Lannois  and  Jaboulay  :  Revue  de  Medecine,  August,  1896,  p.  659. 


Etiology.  351 

bly  metastatic,  in  other  parts  of  the  left  hemisphere.  In 
this  instance,  the  symptoms  were  of  such  absolute  localiz- 
ing significance,  pointing  to  destruction  of  the  left  occi- 
pital lobe  and  of  the  radiations  of  Gratiolet,  that  it  would 
have  been  fully  justifiable  to  lay  open  that  part  of  the 
brain  instead  of  endeavoring  to  draw  off  the  pus  by  punc- 
ture. 

Of  the  other  intracranial  inflammatory  conditions,  that 
of  meningitis  of  the  convexities  and  meningeal  tubercu- 
losis are  the  two  diseases  sometimes  accompanied  by 
aphasia.  In  purulent  leptomeningitis  secondary  to  optic 
disease  aphasia  often  develops,  and,  were  it  not  for  the 
teachings  of  Hugenin,  it  is  probable  that  aphasia  would 
not  be  considered  of  infrequent  occurrence  in  tuberculous 
meningitis.  To  show  the  extent  and  complexity  of  the 
aphasic  symptoms  in  tuberculous  meningitis,  I  need  only 
refer  to  a  case  communicated  by  Carriere,1  in  which  a 
tuberculous  meningitis  (the  lesion  predominating  in  the 
posterior  part  of  the  fissure  of  Sylvius)  was  accompanied 
by  verbal  blindness,  ageusia,  anosmia,  and,  finally,  total 
blindness.  This  case  is  interesting  also  for  the  reason 
that  a  spot  of  recent  softening  was  found  in  the  hippo- 
campal  gyrus.  The  anosmia  was  probably  dependent 
upon  this  lesion,  as  this  would  tend  to  corroborate 
the  claims  of  Jackson,  Beevor,  Carbonieri,  ct  al.,  who 
place  the  cortical  centre  of  smell  in  the  hippocampal 
gyrus. 

Aphasia  may  occur  as  a  symptom  of  direct  injury  to  the 
brain,  and  in  times  of  war  and  riot  such  cases  are  of  com- 
mon occurrence.  A  remarkable  instance  of  destruction  of 

1  Carriere,  G. :  Archives  Cliniques  de  Bordeaux,  1^96,  p.  135. 


352  The  Faculty  of  Speech. 

Broca's  convolution  by  a  foreign  body  is  shown  by  a  case 
of  Simon.1  The  patient  had  been  injured  by  a  fall  from 
a  horse.  After  death  a  splinter  of  bone,  which  had  been 
detached  from  the  inner  table  of  the  skull,  was  fountt  in 
the  left  third  frontal  convolution.  Aside  from  the  cases 
in  which  there  is  solution  of  continuity  of  the  skull,  it 
may  result  from  injury  to  the  head,  such  as  from  a  blow, 
a  fall,  a  kick,  unaccompanied  by  fracture  of  the  skull. 
Whether  or  not  the  lesion  in  some  of  these  cases  is  a 
dynamic  one  cannot  be  said.  Usually  the  aphasic  symp- 
toms in  such  cases  are  neither  so  complete  nor  so  contin- 
uous as  is  aphasia  depending  upon  vascular  lesion.  This 
is  shown  by  an  instance  published  by  Cameron.2  A  young 
man  fell  a  distance  of  fifteen  feet  and  struck  on  the  head. 
He  was  unconscious  for  a  time  and  later  very  restless. 
On  the  seventh  day  after  the  accident  he  had  a  series  of. 
mild  convulsions,  manifest  on  both  sides  of  the  body,  but 
with  special  involvement  of  the  mouth  and  eyes.  After 
this  the  stupor  became  greater,  but  from  the  eighteenth 
day  there  was  a  gradual  clearing  up  of  consciousness. 
On  the  nineteenth  day  he  was  able  to  say  "  Yes"  and 
"No."  On  the  twentieth  day  there  were  aphasia,  alexia, 
and  agraphia.  These  symptoms  disappeared  gradually, 
and  about  six  weeks  after  the  accident  the  patient  was 
quite  well.  In  a  case  of  this  kind,  it  is  much  more  likely 
that  there  was  no  considerable  organic  lesion,  and  that 
the  anatomical  condition  may  be  compared  to  that  which 
is  supposed  to  exist  in  some  cases  of  traumatic  neurosis. 

'Simon:  "A  Case  of  Aphasia."  Johns  Hopkins  Hospital  Bulletin, 
Baltimore,  1889-90,  i.,  p.  48. 

*  Cameron  :  "  Notes  of  a  Case  of  Traumatic  Aphasia."  Glasgow  Medi- 
cal Journal,  August,  1896,  p.  126. 


Etiology.  353 

Therefore  the  aphasia  is  properly  considered  to  be  of  the 
dynamic  variety. 

The  dynamic  aphasias  may  be  dependent  on  functional 
disorders  of  the  brain,  that  term  being  used  in  its  widest 
sense  to  cover  not  alone  states  of  nervous  exhaustion,  but 
to  include  such  diseases  as  epilepsy,  hysteria,  and  migraine. 
They,  as  well  as  the  aphasias  of  toxihaemia,  are  character- 
ized by  the  variability  of  their  manifestations,  the  inter- 
mittency  of  their  course,  the  transitoriness  of  their  dura- 
tion, but  especially  by  their  favorable  outcome.  The  form 
of  aphasia  that  occurs  with  the  neuroses  varies,  and  we 
are  not  in  position  to  s.tate  the  conditions  governing  such 
variation.  In  some  instances,  the  aphasia  will  be  typical 
articulatory  kinaesthetic  aphasia,  while  in  others  the  sensory 
elements  will  predominate.  The  most  common  symptom 
of  the  aphasic  speech  disturbance  attending  migraine 
would  seem  to  be  paraphasia  and  inability  to  name  objects. 
Not  long  ago,  a  hard-working  physician,  about  forty  years 
of  age,  who  had  been  for  a  time  under  my  treatment  for 
epilepsy,  developed  under  the  auspices  of  an  acute  infec- 
tious influenza  a  profound  status  epilepticus,  which  lasted 
nearly  sixty  hours.  He  then  gradually  recovered  con- 
sciousness, but  for  the  next  five  days  had  aphasic  symp- 
toms characterized  particularly  by  loss  of  articulatory  motor 
memories,  as  he  has  since  then  decided  with  me.  After 
he  recovered  consciousness  he  was  wholly  unable  to  speak, 
although  there  was  no  word  deafness,  no  word  blindness, 
nor  was  there  the  slightest  trace  of  disturbance  of  motility 
in  any  part  of  the  body.  He  was  at  this  time  agraphic, 
although  able  to  copy.  I  labored  with  him  for  some  time 
to  get  him  to  pronounce  the  simple  words  "  Yes"  or  "  No" 
23 


354  The  Facility  of  Speech. 

in  response  to  questions  which  he  apparently  understood ; 
showed  him  how  to  say  them  by  fixing  his  lips  and  by 
example,  but  all  to  no  purpose.  He  regained  ability  to 
speak  fluently  and  correctly  within  a  week. 

Another  case  of  epilepsy,  but  in  which  the  aphasic 
symptoms  were  the  result  of  bromide  intoxication,  has 
been  for  me  an  instructive  example.  The  patient  is  a 
young  woman  of  social  position,  who  desires  above  every- 
thing else  not  only  to  remain  free  from  the  convulsive 
attacks  of  her  infirmity  but  to  keep  her  friends  ignorant  of 
it,  and  to  do  this  she  is  willing  to  take  very  large  doses  of 
bromide.  Occasionally  if  hydriatic  and  other  restorative 
procedures  necessary  to  keep  up  the  tone  of  the  nervous 
system  are  at  all  neglected,  she  develops  symptoms  of 
sensory  aphasia,  characterized  especially  by  verbal  am- 
nesia and  mild  degrees  of  word  blindness  and  object 
blindness.  I  have  had  her  maid  make  notes  on  numerous 
occasions  of  the  mistakes  of  utterance  that  are  noticed  at 
these  times,  and  I  quote  here  a  few  of  them.  Wishing  to 
say,  "  I  am  going  to  my  room,"  she  said,  "  I  thick,  think, 
that's  the  stick  thick."  For  "  I  am  going  down  stairs," 
she  said,  "  I  am  going  down  town."  When  she  desired 
the  maid  to  hand  her  a  cup,  she  said,  "  Will  you  give  me 
that  window ;"  and  at  table,  desirous  of  living  up  to  the 
mandates  of  her  physician,  in  refusing  dessert  she  said, 
"  I  do  not  care  for  interest."  She  says  that  oftentimes 
she  finds  herself  conning  a  printed  page  or  a  letter  trying 
to  make  out  what  it  means,  to  decipher  the  words,  and 
then,  all  at  once,  after  looking  at  them  for  a  time,  it  will 
quickly  dawn  upon  her  that  they  are  symbols,  letters,  and 
words  with  which  she  is  familiar.  It  has  also  been  noted 


Etiology.  355 

that  at  such  times,  on  preparing  to  go  for  a  walk  or  a 
drive,  she  will  insist  that  she  cannot  go  without  her  hat, 
while  all  the  time  the  hat  rests  on  her  head  and  she  may 
be  apparently  looking  at  it  in  a  mirror.  There  is  no  de- 
mentia or  trace  of  insanity ;  her  conduct  and  her  actions 
are  in  keeping  with  her  breeding;  and  when  the  bromides 
are  diminished  in  amount  and  restorative  measures  applied 
vigorously  the  aphasic  symptoms  disappear. 

The  genesis  of  aphasia  occurring  with  epilepsy  is  not 
an  easy  matter  to  interpret,  but  it  should  not  be  forgotten 
that  some  cases  of  epilepsy  of  which  it  is  a  symptom  are 
dependent  upon  organic  disease,  such  as  a  tumor,  and 
vascular  lesion,  and  in  every  case  of  epilepsy  in  which 
aphasia  occurs  a  very  careful  examination  is  demanded. 
A  case  recently  reported  by  Hay  prompts  me  to  this  state- 
ment. A  man,  thirty-nine  years  old,  free  from  syphilis, 
suffered  three  attacks  of  influenza  in  rapid  succession,  and 
immediately  afterward  complained  of  great  weakness, 
headache,  depression,  which  brought  him  to  a  very  dis- 
tracted state.  Shortly  afterward  a  condition  of  status 
epilepticus  developed,  and  when  this  terminated  he  had 
aphasia  of  a  sensory  type  and  agraphia.  Six  months  after 
the  beginning  of  the  symptoms  status  epilepticus  devel- 
oped a  second  time,  and  from  this  he  did  not  recover. 
The  autopsy  showed  a  spot  of  softening  in  the  left  tem- 
poral convolution. 

It  does  not  need  the  recitation  of  individual  examples 
to  show  that  aphasia  in  some  of  its  forms,  and  particularly 
sensory  aphasia,  characterized  by  verbal  amnesia  and  par- 
aphasia,  is  a  common  attendant  upon  states  of  mental  ex- 
haustion, especially  when  associated  with  physical  fatigue, 


356  The  Faculty  of  SpcecJi. 

and  upon  preoccupation.  Almost  every  one  who  has  been 
overcome  by  the  former  is  in  possession  of  a  personal  ex- 
ample. Naturally  I  do  not  mean  to  say  that  preoccupation 
produces  aphasia.  What  I  mean  is  that  a  person's  cogni- 
tive areas  maybe  so  intent  upon/subjects  that  engross 
him  that  the  zone  of  language  is  temporarily  ungeared. 
A  very  good  illustration  of  this  is  related  of  Emerson. 
It  is  well  known  that  this  immortal  transcendentalist  was 
wont  to  accompany  himself  with  the  traditional  New  Eng- 
land umbrella  in  his  walks.  On  occasions  when  more 
engrossed  in  absorbing  thought  than  usual,  he  would  hesi- 
tate on  going  out,  search  various  corners,  the  hatrack, 
etc. ,  where  the  cotton  rain  guard  was  usually  to  be  found, 
and  not  finding  it  he  would  stand,  solemnly  tap  the  tem- 
ple or  the  brow,  and  say,  half  to  himself  and  half  to  a  by- 
stander, if  there  happened  to  be  one,  "  Oh,  where — is — , 
where — is, — where — is,  my,  oh — where  is  that  thing  that 
honest  people  take  or  borrow  and  never  think  it  necessary 
to  return  ?"  When  the  word  umbrella  was  suggested, 
"  Yes,  my  umbrella."  Although  this  has  been  utilized  as 
a  contribution  to  "  Umbrella  Pleasantries,"  it  reminds  one 
of  the  patient  described  by  Trousseau,  who,  desiring  the 
same  article,  was  wont  to  say,  "  Where  is  my — u — u — u — 
sacrt  matin  !  "  "  Your  umbrella  ?"  "  Yes,  my  umbrella." 
Genuine  aphasia  is  a  very  rare  accompaniment  of  hys- 
teria, as  rare  correspondingly  as  mutism  is  frequent. 
Why  this  should  be  so,  I  am  at  loss  to  understand.  It 
appears  to  me  that  the  most  reasonable  interpretation  of 
most,  if  not  all,  hysterical  phenomena  is  one  that  posits 
the  partial  abolition  or  perversion  of  function  of  one  or 
more  of  the  cortical  areas.  When  the  involved  cortical 


Etiology.  357 

area  is  the  somaesthetic  or  Rolandic  area,  there  result 
perversions  of  sensibility  and  motility;  when  of  the  pri- 
mary visual  areas,  we  have  hysterical  blindness ;  when  of 
the  auditory  area,  we  have  hysterical  deafness ;  and  when 
of  the  frontal  lobes,  we  have  diverse  and  protean  psychi- 
cal manifestations.  Thus  it  would  seem  to  me  that  a 
dynamic  perversion  of  the  zone  of  language  analogous  to 
the  condition  that  forms  the  basis  of  the  above-mentioned 
phenomena  might  produce  aphasia;  but  as  a  matter  of 
fact  there  are  very  few  examples  of  hysterical  aphasia  on 
record. 

Hysterical  aphasia  is  usually  less  transitory  than  are 
other  forms  of  dynamic  aphasia,  but,  unlike  hysterical 
aphonia,  it  does  not  extend  over  months  and  years.  It 
may  be  the  only  major  symptom  of  hysteria  or  it  may  be 
associated  with  hysterical  hemiplegia  and  contracture  or 
with  contracture  in  other  parts  of  the  body.  It  is  more 
frequently  seen  accompanying  traumatic  hysteria,  than 
with  the  so-called  idiopathic  form.  Aphasia  analogous  to 
the  hysterical  form  has  been  artificially  produced  in  per- 
sons by  hypnotism. 

In  studying  the  aphasic  speech  disturbances  which 
sometimes  accompany  neuralgic  affections  of  the  migrai- 
nous  order,  it  is  well  to  keep  in  mind  the  genetic  relation- 
ship existing  between  migraine  and  epilepsy.  Usually 
the  aphasic  disturbances  of  migraine  are  of  a  sensory 
character  and  very  transitory.  In  discussing  the  relation 
of  amusia  to  aphasia,  I  have  cited  one  or  two  examples  of 
the  aphasia  of  migraine,  and  shall  here  refer  only  to  one 
example  recently  published  by  Pick.1  A  young  physician 

1  Pick  :  Berliner  klinische  Wochenschrift,  1894,  No.  47. 


358  The  Faculty  of  Speech. 

who  had  lived  a  very  irregular  life  developed  suddenly 
symptoms  of  ophthalmic  migraine,  with  which  were  asso- 
ciated motor  aphasia,  word  deafness,  and  echolalia,  all  of 
which  disappeared  with  the  attack. 

It  has  been  suggested  that  the  genesis  of  migrainous 
aphasia  is  in  reality  a  vascular  one,  a  contraction  of  the 
cortical  blood-vessels  of  the  left  hemisphere,  which  causes 
a  perversion  of  function  of  the  zone  of  language.  This  is 
a  very  plausible  supposition,  considering  the  very  striking 
evidences  of  vasomotor  instability  in  other  parts  of  the 
body  that  occur  with  migraine,  but  it  is  easily  understood 
that  there  are  insurmountable  difficulties  in  the  way  of 
adducing  proof  of  this  hypothesis. 

There  is  an  amount  of  very  convincing  evidence  on 
record  to  show  that  certain  drugs,  such  as  santonin,  bella- 
donna, tobacco,  etc.,  of  the  vegetable  poisons,  sometimes 
produce  aphasia  when  given  in  toxic  doses.  There  is 
nothing  especially  characteristic  of  such  aphasia  to  aid  us 
in  differentiating  it  from  other  dynamic  forms,  and  the 
aphasia  can  be  suspected  to  be  of  such  origin  only  when  it 
is  known  that  the  patient  has  exposed  himself  to  one  of 
these  poisons.  If  the  cause  can  be  discovered  and  re- 
moved, the  aphasic  symptoms  soon  disappear,  and  this, 
more  than  anything  else,  stamps  their  origin. 

This  leads  me  to  speak  of  other  toxic  conditions  that 
iviay  cause  aphasia,  particularly  uraemia,  diabetes,  and 
gout,  as  well  as  more  uncommon  forms  of  poisoning,  such 
ag  snake  bite,  etc.,  and  of  the  aphasia  which  sometimes 
occurs  with  Raynaud's  disease.  Aphasia  is  an  extremely 
uncommon  complication  or  coincident  symptom  of  Ray- 
naud's disease,  symmetrical  gangrene.  I  have  been  able 


Etiology.  359 

to  find  but  two  references  to  it  in  the  literature,  one  by 
Weiss;  '  another  by  Osier.2  Personally  I  have  seen  one 
case.  A  young  man  was  brought  into  the  hospital  suffer- 
ing from  symmetrical  gangrene  of  both  feet,  slight  cyano- 
sis of  the  tip  of  the  nose  and  the  upper  part  of  both  ears, 
and  with  the  general-collapse  symptoms  attending  the 
advanced  stage  of  this  disease.  He  was  thought  to  be 
demented  or  amented  by  some  members  of  the  house  staff 
who  saw  him,  because  it  was  impossible  to  extract  any  in- 
formation from  him.  He  could  not  tell  his  name,  age, 
residence,  occupation,  or  anything  about  his  illness, 
neither  could  he  be  got  to  write  or  read.  Ability  to 
articulate  words  was  preserved,  for  he  would  occasionally 
use  words,  but  they  could  not  be  understood  or  interpreted, 
i.e.,  they  were  without  sense.  Under  tonic  and  stimulat- 
ing treatment,  including  large  doses  of  nitroglycerin,  he 
improved  slowly,  and  eventually  the  sensory  aphasia  dis- 
appeared. 

The  patient  with  Raynaud's  disease  described  by  Osier 
had  three  attacks  of  transitory  right-side  hemiplegia  and 
aphasia,  and  died  six  months  after  the  third  attack.  In 
my  patient  there  was  no  trace  of  hemiplegia.  It  is  not 
at  all  unlikely  that  the  aphasia  in  these  cases  is  dependent 
upon  vascular  conditions  in  the  brain  similar  to  those  in 
the  extremities  that  become  blanched  and  then  cyanosed. 
Unless  the  disease  is  very  severe  the  aphasia  is  not  com- 
plete, and  may  manifest  itself  only  in  paraphasia  and  diffi- 
culty in  interpreting  spoken  and  written  language.  When 
the  affection  of  the  cerebral  blood-vessels  is  so  profound 

1  Wiener  Klinik,  1882. 

8  American  Journal  of  the  Medical  Sciences,  vol.  cxii.,  1896. 


o 


60  The  Faculty  of  Speech. 


as  to  cause  hemiplegia  the  aphasia  is  usually  total.  In 
my  patient  the  disturbance  of  speech  was  mainly  on  the 
receptive  side  of  language,  and  there  was  no  disturbance 
of  locomotion  except  that  conditioned  by  the  peripheral 
manifestations  of  the  disease  and  the  asthenia  which  is 
always  such  a  profound  symptom. 

Of  the  toxic  aphasias,  that  produced  by  uraemia  is  by 
far  the  most  common.  It  may  be  a  mistake  to  include  it 
in  the  dynamic  aphasias,  for  it  must  be  classed  with  the 
cerebral  symptoms  of  a  paralytic  order,  provoked  by  a  toxic 
substance  in  the  blood.  Uraemic  aphasia  is  seen  oftener 
in  the  old  than  in  those  of  middle  age,  and  oftener  in  chil- 
dren than  at  any  other  time  of  life.  The  frequency  of 
ursemic  aphasia  in  children  is  accounted  for  by  the  fact 
that  post-scarlatinal  nephritis  and  nephritis  following  other 
infectious  diseases  are  more  common  at  this  time  of 
life.  During  the  years  of  fullest  maturity,  uraemic  symp- 
toms are  more  liable  to  be  dependent  upon  cirrhotic  kidney 
than  upon  any  other  form  of  kidney  disease.  Clinically, 
uraemic  aphasia  is  more  commonly  of  a  mixed  form  than  it 
is  visual,  auditory,  or  articulatory,  but  of  course  this  de- 
pends, as  does  the  determination  of  the  variety  of  aphasia 
in  any  given  case,  upon  the  part  of  the  zone  of  language 
that  is  predominantly  affected. 

In  cases  of  transitory  aphasia,  accompanying  grippe, 
pneumonia,  etc.,  the  aphasic  symptoms  frequently  come 
on  after  the  patient  has  been  "  flighty"  or  delirious,  and 
usually  the  motor  form  predominates.  A  case  of  this 
kind  is  reported  by  Isager.1  A  child  ceased  to  speak  after 

1  Isager  :  "  Et  Tilfalde  af  Afasi  i  Tilslutning  til  en  krupos  Pneumoni  " 
Hosp.  Tid.,  1894,  p.  42. 


Etiology.  361 

the  crisis  of  a  croupous  pneumonia.  He  understood  fully 
what  was  said,  he  could  not  speak  voluntarily,  he  could 
not  repeat,  nor  could  he  read  aloud.  There  was  no  paral- 
ysis, and  after  a  week  he  began  to  use  individual  words, 
and  in  the  course  of  a  few  days  the  faculty  of  speech  was 
quite  restored. 

It  is  not  at  all  unlikely  that  cases  of  aphasia  occurring 
with  lead  poisoning  are  in  reality  dependent  upon  a  lead 
encephalopathy,  and  the  aphasic  symptom  complex  may 
be  looked  upon  as  a  focal  or  localizing  symptom.  This 
leads  me  to  say  another  word  anent  the  aphasic  speech 
disturbances  of  the  specific  fevers.  A  great  deal  of  atten- 
tion has  been  devoted  to  this  subject,  and  it  is  by  no 
means  settled  that  the  majority  of  cases  belong  to  the  one 
form  of  aphasia,  organic,  or  to  the  other,  dynamic.  It  is 
likely  that  some  are  of  the  first  kind  and  others  are  of  the 
second.  It  is  known  that  the  infectious  diseases  predis- 
pose very  materially  to  septic  states  of  the  blood,  to  phle- 
bitis, to  endocarditis,  and  to  other  conditions  directly 
causative  of  embolism  and  thrombosis,  and  thus  in- 
directly to  organic  aphasia  by  producing  an  obstruc- 
tion of  the  middle  cerebral  artery  and  its  branches 
which  supply  the  zone  of  language,  and  which  leads  to 
softening. 

The  aphasic  speech  disturbances  that  are  sometimes, 
though  rarely,  associated  with  chorea,  primary  degenera- 
tive tic,  and  with  different  forms  of  peripheral  irritation, 
usually  called  reflex,  such  as  from  intestinal  worms,  phi- 
mosis,  etc.,  are  very  uncommon,  although  the  existence  of 
cases  of  this  kind  seems  to  be  well  substantiated.  They 
do  not  call  for  particular  discussion.  The  aphasia  is  to 


362  The  Faculty  of  Speech. 

be  looked  upon  as  the  result  of  reflex  inhibitory  phenom- 
ena and  purely  dynamical  in  constitution. 

Aphasic  symptoms  occasionally  develop  after  a  consid- 
erable loss  of  blood,  such  as  from  epistaxis  (Berthold), 
rupture  of  varix  (Storp),  post-partum  hemorrhages,  or  sim- 
ilar conditions  causing  acute  anasmia.  Hallervorden1  de- 
plores that  so  little  attention  is  given  by  writers  on  the 
etiology  of  aphasia  to  acute  anaemia.  As  a  matter  of  fact, 
unless  the  loss  of  blood  causes  a  marantic  thrombus  in 
some  cortical  branch  of  the  left  Sylvian  artery,  genuine 
aphasia  is  an  excessively  rare  symptom  of  such  hemor- 
rhages. Sudden  partial  exsanguination  is  often  accom- 
panied by  dysarthria,  sometimes  by  anarthria,  but  these 
are  bulbar  symptoms,  just  as  the  syncopal  attacks  that 
often  occur  from  the  same  cause  are  bulbar  manifesta- 
tions. True  aphasia,  the  result  of  loss  of  blood,  is  usu- 
ally partial,  and  may  be  manifest  through  both  the  recep- 
tion and  the  emission  of  speech.  It  is  usually  transitory 
and  is  one  of  the  first  exhaustion  symptoms  to  disappear. 

There  remain  to  be  discussed  in  the  etiology  of  aphasia 
two  of  the  most  important  organic  diseases  of  which 
aphasia  is  a  symptom.  These  are  tumor  of  the  brain  and 
cerebral  apoplexy.  Aphasia  as  a  localizing  symptom  of 
new  growth  in  the  brain  is  one  of  the  most  important  and 
trustworthy  guides.  As  a  rule,  tumor  presents  the  ideal 
lesion  to  cause  a  strictly  confined  destruction  of  one  of 
the  centres  in  the  zone  of  language.  At  least,  I  mean  to 
say,  that  it  is  so  at  the  beginning  of  the  tumor.  Tumors 
begin  in  the  great  majority  of  cases  in  one  of  two  ways  :  by 
a  proliferation  of  the  tissue  of  the  part  which  is  pathologi- 

1  Hallervorden  :  Deutsche  med.  Wochenschrift,  vol.  xxii.,  No.  5,  1895. 


Etiology.  363 

cal  from  the  beginning,  or  by  the  appearance  of  a  tissue 
that  is  foreign  to  the  part.  In  the  beginning  the  abnor- 
mality is  small,  perhaps  microscopical.  It  maybe  strictly 
confined  to  an  area  that  has  such  highly  individualized 
function  as  the  angular  gyrus,  the  first  temporal  convolu- 
tion, or  to  a  definite  part  of  the  motor  area,  and  at  such 
time  it  will  produce  symptoms  of  almost  mathematical 
precision.  These  symptoms  may  occur  before  the  symp- 
toms of  brain  tumor,  that  are  so  consecrated  by  time  that 
they  are  called  cardinal,  develop.  If  the  physician  takes 
proper  recognition  of  them  and  gives  proper  interpretation 
to  them,  such  perspicuity  on  his  part  may  be  rewarded  by 
the  life  of  the  patient.  It  is  not  necessary  to  point  out 
in  detail  what  these  varicus  symptoms  are.  If  one  has  in 
mind  the  topography  of  the  surface  of  the  cortical  sub- 
stance, and  the  functions  allotted  to  it,  as  well  as  an  un- 
derstanding of  the  connecting  pathways  of  these  cortical 
areas,  it  is  unnecessary  to  make  explicit  recitation  of  such 
symptoms. 

Aphasia  may  be  a  prominent  symptom  of  a  recoverable 
form  of  tumor,  gumma,  and  therefore  the  importance  of 
recognizing  it  and  applying  appropriate  treatment  is  ap- 
parent. A  most  instructive  case,  showing  not  alone  the 
amenability  to  treatment  of  very  profound  forms  of  sensory 
aphasia  when  due  to  syphilitic  lesion,  but  also  the  accu- 
racy with  which  such  a  lesion  can  be  localized  from  the 
clinical  data,  is  one  recently  reported  by  Bramwell.1  A 
young  widow,  who  had  had  several  miscarriages  and  abor- 
tions, complained  after  repeated  exposure  to  the  sun's  rays, 
while  working  in  the  fields,  of  severe  headache,  worse  at 

1  Bramwell :  "  Illustrative  Cases  of  Aphasia."     Lancet,  1897. 


364.  Tke  Faculty  of  Speech. 

night ;  mental  stupidity  and  loss  of  memory  (she  stated 
that  she  felt  as  if  she  was  in  a  misti  ;  and  dimness  of 
vision.  On  examination  there  were  found  slight  optic  neu- 
ritis, right-sided  homonymous  hemianopsia,  almost  com- 
plete word  blindness,  complete  agraphia.  She  could  not 
write  spontaneously,  from  dictation,  or  from  copy.  There 
was  inability  to  name  objects  correctly,  and  when  she  tried 
to  name  she  nearly  always  applied  the  wrong  name,  al- 
though she  recognized  when  others  called  things  by  the 
wrong  name.  The  auditory  speech  centre  was  practically 
normal,  as  was  likewise  the  articulatory  speech  centre. 
Soon  after  iodide  of  potassium  was  prescribed  the  symp- 
toms began  to  be  ameliorated,  the  headache  was  relieved, 
the  mental  condition  cleared  up,  the  word  blindness  and 
the  agraphia  disappeared,  and  the  fields  of  vision  gradually 
enlarged  until  at  the  date  of  her  discharge  they  were  quite 
normal.  She  regained  possession  of  the  modes  of  speech 
in  the  following  order:  First,  ability  to  name  objects; 
then  ability  to  read  letters  and  words,  but  at  this  stage 
she  was  completely  unable  to  write  spontaneously,  to  copy 
letters,  or  to  write  from  dictation;  then  she  gradually 
found  herself  able  to  read  a  little  more  each  clay,  and  in 
the  course  of  a  few  days  to  write  a  few  letters.  It  is 
worthy  of  remark  that  before  she  regained  the  ability  to 
write  letters  she  seemed  to  have  an  idea  of  the  letters, 
that  she  wished  to  write ;  in  other  words,  she  could  evoke 
them  in  her  mind.  This  is  shown  by  the  fact  that  when 
she  was  asked  if  she  did  not  know  the  letter  a  she  said 
that  she  did,  that  it  was  an  o  with  a  crook.  Finally,  she 
regained  the  power  of  writing  fully,  and  at  the  time  she 
was  discharged  from  the  hospital  every  one  of  the  aphasic 


Etiology.  365 

symptoms,  without  exception,  had  yielded  to  antisyphilitic 
treatment. 

I  have  recently  had  a  very  similar  experience.  A  young 
married  woman  whose  manifestations  of  constitutional 
syphilis  were  repeated  abortions  and  exfoliating  necrosis 
of  the  palatal  region  of.  the  upper  jaw  began  to  complain 
of  headache,  nervousness,  flightiness,  depressed  states 
of  mind  with  frequent  crying-spells,  and  of  trouble  in  see- 
ing. Later,  she  complained  of  a  subjective  feeling  of 
numbness  and  unwieldiness  in  the  right  hand.  This  was 
followed  after  a  few  weeks  by  a  convulsive  attack  begin- 
ning in  the  right  hand  and  involving  the  entire  extremity, 
without  loss  of  consciousness.  After  the  convulsion 
ceased  she  was  unable  to  speak  and  to  write  for  several 
hours.  There  was  no  hemianopsia,  apparently  no  disturb- 
ance on  the  receptive  side  of  language,  and  she  could  under- 
stand what  was  said  to  her.  She  had  three  attacks  simi- 
lar to  this,  and  after  the  last  of  them  I  saw  her.  The 
twitching  of  the  right  upper  extremity  had  ceased  and 
there  was  no  evidence  of  hemiplegia,  but  the  patient  had 
well-marked  symptoms  of  cortical  motor  aphasia,  which 
gradually  disappeared  after  several  hours.  She  made  a 
complete  recovery  under  treatment  by  mercury  and  the 
iodides.  All  the  symptoms,  including  a  slight  degree  of 
choked  discs,  had  disappeared  at  the  end  of  two  months' 
energetic  antisyphilitic  and  restorative  treatment. 

This,  then,  shows  clearly  that  the  etiology  of  aphasia, 
and  that,  too,  of  organic  aphasia,  has  a  most  important 
bearing  on  the  course  and  outcome  of  the  symptom  and 
on  determining  the  treatment.  In  Bramwell's  case  the 
lesion,  although  it  did  not  destroy  the  higher  visual  centre 


366  The  Faculty  of  Speech. 

in  the  angular  gyrus,  made  such  inroads  upon  the  latter 
that  it  determined  its  functional  overthrow,  as  indicates 
the  agraphia,  writing  in  all  of  its  modes  having  been  lost, 
while  the  homonymous  hemianopsia  and  the  alexia,  the  in- 
ability to  apply  the  proper  names  to  objects,  showed  that 
the  way  from  the  primary  visual  centres  in  the  gray  mat- 
ter of  the  occipital  lobes  around  the  calcarine  fissure  to 
the  higher  visual  centre  was  severely  encroached  upon. 

The  efficaciousness  of  prompt  and  energetic  treatment 
directed  against  the  luetic  meningitis  or  the  gummatous 
encroachment  upon  the  cortex  is  shown  very  strikingly  by 
the  disappearance  of  the  symptoms  in  my  own  patient. 

Of  the  large  number  of  examples  of  cases  of  brain 
tumor  whose  existence  was  directly  pointed  by  the  pres- 
ence of  aphasic  symptoms,  I  shall  cite  but  one  example, 
and  that  recorded  by  Walton.  The  patient  was  a  man, 
forty  years  old,  who  suffered  from  gradually  increasing 
attacks  of  headache,  at  first  of  brief  duration,  later  continu- 
ous, together  with  difficulty  in  speech  ("ataxic  aphasia"). 
He  complained  of  red  spots  in  the  field  of  vision,  and  ex- 
amination showed  word  deafness,  word  blindness,  and 
right-side  hemianopsia,  in  addition  to  double  optic  neuritis 
and  paralysis  of  the  left  abducens.  The  patient  was  tre- 
panned, but  after  the  skull  was  opened  it  was  decided  that 
the  tumor  was  too  deeply  seated  and  too  extensive  to  war- 
rant interference.  The  patient  died  two  months  after  the 
operation.  The  autopsy  showed  a  more  or  less  lobulated 
pear-shaped  mass,  occupying  the  region  of  the  posterior 
parietal  and  anterior  part  of  the  occipital  lobe  on  the  left 
side,  loosely  attached  in  some  places  to  the  brain  sub- 
tance,  infiltrating  it  in  others.  The  temporal  lobe  was 


Etiology.  367 

pushed  downward,  the  occipital  backward.  The  growth 
reached  practically  to  the  mesial  surface,  and  on  micro- 
scopic examination  it  was  found  to  be  a  glioma. 

In  this  case,  therefore,  the  symptoms  were  most  path- 
ognomonic  and  suggested  with  great  accuracy  the  locus  of 
the  growth.  A  lesion  that  will  produce  word  blindness, 
left-side  homonymous  hemianopsia,  and  word  deafness 
can  be  situated  only  in  the  angular  gyrus,  extending  far 
enough  centrally  to  sever  the  radiations  of  Gratiolet,  and 
downward  to  impinge  upon  the  auditory  centre  in  the  first 
temporal  convolution  of  the  left  side.  This  case  furnishes 
opportunity  to  say  another  word  concerning  the  laxity  in 
the  use  of  terms  by  even  those  most  worthy  of  the  name 
of  cultured  neurologists.  In  this  case  it  was  said  that 
there  was  ataxic  aphasia.  Now,  in  addition  to  the  fact 
that  no  designation  of  medical  terminology  is  more  indefi- 
nite than  ataxic  aphasia,  it  may  also  be  said  that  for  the 
reader  who  would  judge  of  the  speech  defects  in  the  case 
from  the  published  report  there  was  nothing  to  point  the 
existence  of  articulatory  motor  aphasia ;  nor  was  there  any 
lesion  found  on  autopsy  that  would  point  to  the  existence 
of  such  a  condition.  Moreover,  it  is  difficult  to  say  from 
the  autopsy  report  alone  whether  or  not  the  cortical  sub- 
stance of  the  angular  gyrus  was  completely  destroyed. 
One  infers  that  it  was  not,  because  the  tumor  was  appar- 
ently out  of  the  reach  of  the  surgeon  and  could  not  have, 
therefore,  forced  its  way  to  the  surface ;  otherwise  a  part, 
at  least,  of  it  would  have  been  removed.  I  wish  hence  to 
reiterate  that,  in  the  report  both  of  the  clinical  side  of  a 
case  and  of  the  anatomical  side  of  a  case,  those  who  would 
contribute  to  the  real  study  of  aphasia  and  thus  to  the 


368  The  Faculty  of  Speech. 

tomes  of  physiology,  psychology,  and  biology,  should  be 
mindful  ever  of  the  need  of  accurate  statements  and  of 
detailed  description. 

So  frequently  is  aphasia  an  accompaniment  of  apoplexy, 
a  term  which  I  use  to  include  rupture  of  a  blood-vessel, 
obliteration  of  its  calibre,  and  acute  softening,  that  in  the 
minds  of  many  physicians  the  word  aphasia  suggests 
apoplexy.  The  genetic  and  anatomical  relationship  exist- 
ing between  the  zone  of  language  and  the  middle  cerebral 
artery  has  already  been  mentioned,  and,  as  the  subject  will 
be  considered  in  extenso  in  the  chapter  on  "  Morbid 
Anatomy  of  Aphasia,"  it  is  referred  to  here  in  the  briefest 
manner.  Nor  do  I  think  it  necessary  in  a  chapter  on  the 
etiology  of  aphasia  to  remark  on  the  causative  factors  of 
cerebral  apoplexy. 

Of  the  organic  mental  diseases  that  aphasia  may  be  a 
symptom  of,  general  paresis  is  the  most  important.  In 
the  beginning  of  this  disease,  which  is  pathologically  a 
widespread  degeneration  of  the  cortex,  the  most  prominent 
symptom  may  be  aphasia.  This  probably  coincides  with 
a  beginning  degeneration  in  some  part  of  the  zone  of  lan- 
guage. Usually  the  aphasia  is  of  the  sensory  type. 

There  remains  but  one  form  of  aphasia  to  be  mentioned, 
and  this  chapter  is  finished,  and  that  is  the  form  known  as 
congenital  aphasia,  or  congenital  limitation  of  speech  de- 
velopment. These  cases  are  not  very  uncommon.  Kuss- 
maul  described  a  number  of  instances  more  than  a  quarter 
of  a  century  ago,  and  recently  Gutzmann  has  studied  the 
subject  very  carefully.  Congenital  aphasia  may  be  partial 
or  it  may  be  complete.  I  do  not  include  in  this  catesrorv 
lack  of  speech  development  dependent  upon  porencephalia 


Etiology.  369 

or  other  gross  lesions  of  the  cerebral  hemisphere.  Aside 
from  the  disturbances  in  the  organs  of  perception  which 
are  a  part  of  idiocy,  there  is  a  not  inconsiderable  number 
of  cases  in  which,  without  any  disease  of  the  peripheral 
percipient  sensory  apparatuses,  or  of  the  central  sensory 
perceptual  areas,  there  is  a  condition  of  speechlessness, 
and  that,  too,  entirely  divorced  from  any  apparent  disturb- 
ance of  intelligence.  It  is  to  these  cases  that  Coen1  gives 
the  name  of  auditory  dumbness  in  contradistinction  to 
deafness  and  dumbness.  Although  these  children  do  not 
present  gross  mental  or  psychical  defect,  usually  careful 
examination  shows  that  there  are  always  a  certain  amount 
of  abulia,  tardiness  in  learning  to  walk,  slowness  in  ac- 
quiring skill  of  any  kind,  and  '/arious  other  manifestations 
of  psychic  and  somatic  degeneration.  A  very  remarkable 
feature,  and  one  that  should  be  borne  in  mind  when  in  the 
presence  of  such  cases,  is  that  in  about  one-third  of  them 
there  have  been  found  adenoid  vegetations.  The  only 
other  etiological  factors  that  can  be  enumerated  are  that 
this  condition  has  been  met  with  more  frequently  in  males 
than  in  females,  and  that  there  is  almost  always  a  neuro- 
pathic heritage,  particularly  from  the  father's  side,  and 
that,  although  a  great  many  of  these  patients  acquire  con- 
siderable speech  facility,  it  is  often  later  in  life  associated 
with  stammering. 

1  Coen  :  Wiener  klinische  Rundschau,  1893,  No.  6 

24 


CHAPTER    X. 
MORBID  ANATOMY  OF  APHASIA. 

WERE  one  to  write  the  morbid  anatomy  of  aphasia  in 
detail,  he  must  needs  consider  the  various  disease  processes 
forming  the  basis  of  all  the  organic  and  functional  dis- 
eases, enumerated  in  the  chapter  on  etiology,  with  which 
aphasia  may  be  associated  symptomatically.  Such  de- 
scription would  carry  us  far  beyond  the  limits  put  upon 
this  work.  Indeed,  I  doubt  if  such  consideration  could  be 
made  to  serve  any  useful  purpose  in  elucidating  the  intri- 
cacies of  aphasia.  Never  for  a  moment  should  we  forget 
that  aphasia  is  a  symptom;  and,  although 'it  is  the  most 
comprehensive  symptom  that  a  physician  has  to  deal  with, 
it  nevertheless  always  remains  a  symptom.  It  has  already 
been  said  that  one  associates  in  his  mind  almost  invol- 
untarily the  symptom  aphasia  with  the  disease  apoplexy, 
because  it  is  with  apoplexy,  using  this  term  generically 
to  include  hemorrhage,  occlusion  of  the  cerebral  blood- 
vessels, and  acute  softening,  that  aphasia  most  frequently 
occurs.  Notwithstanding  this,  a  discussion  of  the  various 
forms  and  stages  of  cerebral  hemorrhage  and  cerebral  soft- 
ening cannot  be  attempted  here. 

In  reality  aphasia  due  to  lesion  of  the  speech  centres, 
true  aphasia,  is  not  often  dependent  upon  cerebral  hemor- 
rhage, and  this  for  the  reason  that  cerebral  hemorrhage 
limited  to  the  cortex  is  an  extremely  rare  condition.  On 


Morbid  Anatomy  of  Aphasia.  371 

the  other  hand,  acute  softening  following  the  occlusion  of 
one  of  the  cortical  vessels  is  not  so  rare.  Aphasia  is 
rarely  dependent  upon  hemorrhage  in  the  basal  region,  for 
rupture  of  the  trunk  of  the  middle  cerebral  artery  before 
it  gives  off  the  ganglionic  arteries  is  such  a  serious  con- 
dition that  its  occurrence  is  rarely  consistent  with  the 
continuance  of  life.  In  young  persons,  however,  the  main 
trunk  of  the  Sylvian  artery  may  be  occluded  at  any  level 
beyond  the  branching  ganglionic  branches,  and  yet  no 
softening  take  place.  This  accounts  for  the  transient- 
ness  of  aphasia  in  young  people  and  for  the  rapidity 
and  completeness  of  their  recovery.  The  first  of  the 
author's  cases  cited  in  this  monograph  is  an  excellent 
example  of  such  speedy  recovery,  even  in  a  very  severe 
form  of  intracerebral  vascular  disease.  A  more  convinc- 
ing example,  because  accompanied  by  an  autopsical  report, 
has  been  published  by  Ross.1  A  young  girl,  while  suffer- 
ing from  endocarditis,  had,  first,  embolus  of  the  femoral 
artery,  and  in  rapid  succession  embolus  of  the  kidneys, 
spleen,  and  left  Sylvian  artery,  occlusion  of  the  latter 
being  evinced  by  an  attack  of  right-side  hemiplegia  and 
combined  motor  and  sensory  aphasia.  The  patier\t  died 
from  exhaustion  about  a  fortnight  after  the  attack  of 
aphasia.  There  was  found  in  the  main  trunk  of  the 
Sylvian  artery,  a  little  outside  the  anterior  perforated 
space,  but  proximally  to  any  of  the  cortical  branches,  a 
very  firm  occlusion.  Not  the  slightest  amount  of  soften- 
ing could  be  discovered,  although  Ross  states  that  it  is 
very  likely  that  the  nerve  cells  supplied  by  the  Sylvian 

'Ross:    "Aphasia."     Wood's  "Medical    and  Surgical    Monographs," 
vol.  vi..  No.  I,  1890. 


372  The  Faculty  of  Speech, 

artery  had  undergone  fatty  degeneration.  There  can  be 
little  doubt,  judging  from  the  outcome  of  analogous  cases, 
that,  had  the  patient  lived,  the  nutritive  and  functional 
activity  of  the  tissues  of  this  area  would  have  been  grad- 
ually restored.  Such  an  outcome  should  not  be  at  all  sur- 
prising when  we  consider  that  the  cortical  branches  of 
this  artery,  unlike  the  ganglionic  branches,  are  not  ter- 
minal ones. 

Although  the  study  of  the  morbid  anatomy  of  aphasia 
really  began  with  Broca  when  he  made  an  autopsy  on  his 
first  aphasic  patient,  Leborgne,  previous  writers  on  the 
subject  of  speech  and  its  defects  were  not  without  anatom- 
ical data  to  fortify  their  contentions,  and  of  these  may  be 
mentioned  Bouillaud  '  and  Dax,"  who  based  their  infer- 
ences on  not  an  inconsiderable  pathological  experience. 
Broca's  first  case  was  one  that  is  usually  looked  upon  as  a 
typical  example  of  cortical  motor  aphasia,  but  to-day  it 
would,  I  believe,  be  considered  one  of  subcortical  motor 
aphasia,  as  the  lesions  found  were  widely  distributed  on 
the  surface  and  in  the  substance  of  the  left  hemisphere. 
Although  one  of  his  cases  showed  extensive  involvement 
of  the  auditory  area,  the  father  of  aphasia  persisted  in  the 
belief  that  the  seat  of  lesion  causing  aphasia  was  in  every 
instance  in  the  posterior  part  of  the  third  frontal  convolu- 
tion on  the  left  side. 

It  would  be  supererogatory  to  enumerate  even  a  part  of 
the  great  number  of  autopsies  to  show  that  destruction  of 
Broca's  convolution  is  attended  by  symptoms  constituting 
the  symptom  complex  of  cortical  motor  or  articulatory 

1  Bouillaud  :    "  Traite  Clinique  et  Physiologique  de  1'Kncephalite,"  1823. 

2  Dax  :    Gazette  Hebdomadaire,  .April,  1895,  No.  17.      Republished. 


Morbid  Anatomy  of  Aphasia.  373 

kinaesthetic  aphasia.  This  is  something  that  every  one 
admits.  In  the  chapter  on  etiology  of  aphasia  the  rela- 
tion of  the  area  of  Broca  to  the  first  cortical  branch  of  the 
middle  cerebral  artery  has  been  alluded  to,  and  likewise 
the  liability  of  this  part  of  the  cortex  to  be  diseased. 
When  it  is  diseased,  a  complexity  of  symptoms  is  produced 
that  varies  with  the  completeness  of  destruction.  The 
lesions  that  are  found  there,  constituting  the  organic 
basis  of  cortical  motor  aphasia,  circumscribed  encephalo- 
malacia,  localized  gummatous  meningitis,  tumors,  abscess, 
purulent  leptomeningitis,  penetrating  wounds,  were  also 
discussed  in  the  chapter  on  etiology  and  need  no  further 
enumeration  here. 

Future  study  of  morbid  changes  accompanying  motor 
aphasia  should  be  particularly  with  two  ends  in  view  :  first, 
to  separate  closely  subcortical  or  pure  motor  aphasia  from 
motor  image  aphasia,  due  to  destruction  of  the  area  of 
Broca ;  and  second,  to  show  that  when  the  disease  process 
is  limited  to  the  latter  area  there  is  absolutely  no  second- 
ary degeneration  in  any  projection  tract  such  as  has  been 
described  by  Pitres,  Raymond,  Brissaud,  and  many  others 
as  occurring  in  the  inferior  pediculo-frontal  fascicle.  To 
do  this  microscopical  study  of  every  case  is  necessary.  In- 
vestigation of  this  kind  can  do  for  the  motor  side  of 
aphasia  what  the  microscopical  studies  instituted  by  De- 
jerine  have  done  for  the  sensory  side  of  aphasia.  One 
cannot  overestimate  the  importance  of  such  microscopical 
study  until  he  examines  the  literature  and  finds  how  easy 
it  is  to  put  different  interpretations  on  the  same  case,  if 
only  the  gross  lesion  is  described.  Incomplete  anatomical 
investigation  must  account  in  some  instances  for  the  in- 


374  The  Faculty  of  Speech. 

terpretations  of  some  of  the  cases  that  have  been  cited  by 
authors  to  prove  the  existence  of  a  graphic-motor  centre, 
such  as  that  of  Henschen,1  for  example.  The  patient  suf- 
fered from  word  blindness  and  agraphia,  and  after  death 
there  was  found  not  only  destruction  of  the  foot  of  the 
second  frontal  but  also  a  softening  of  the  angular  gyrus.2 

1  Henschen  :   "  Klin.  u.  anatom.  Beitrage  zur  Pathologic   des  Gehirns," 
Upsala,  1890-94. 

2  I  am  constrained  to  mention  again,  at  the  risk  of  wearying  the  reader 
beyond  justification,  the  fact  that  just  so  long  as  writers  on  aphasia  refuse 
closely  to  differentiate  cortical  from  subcortical  forms  of  motor  aphasia,  just 
so  much  longer  will  it  be  before  the  question,  "  Does  destruction  of  Broca's 
convolution  entail  agraphia?"  is  settled  to  the  satisfaction  of  .every  one.      I 
am  prompted  to  these  remarks  from  an  examination  of  the  first  of  Bastian's 
recent  lectures,  which  are  now  appearing  in    The  Lancet.     No  one  can  be 
more  profoundly  cognizant  of  the  fact,  that,  as  a  writer  on  speech  disturb- 
ances, Dr.  Bastian  should  rank  with  the  Fathers  of  Aphasia,  with  Broca  and 
Wernicke.      It  is  not  hazarding  the  truth  to  say  that   he   has  contributed 
more    to  the  elucidation  of  the  genesis  of  speech   than  has  any  English 
writer.      My  astonishment  is  therefore  the  greater  that  the  following  case, 
quoted  from  Wadham,  should  be  offered  in  evidence   to  negative  the  claim 
that  cortical  motor  aphasia  always  entails  agraphia.     I  venture  to  state  that 
if  there  has  ever  been  a  case  published  which  is  a  mirror  held  up  to  the 
symptom  complex  and  morbid  anatomy  of  subcortical  motor  aphasia,  it  is 
the  one  just  mentioned  and  which  I  now  proceed  to  quote. 

"  A  youth,  aged  eighteen,  left-handed  and  ambidexterous,  became  partly 
hemiplegic  on  the  left  side  and  completely  speechless  after  long  exposure  to 
cold.  Twelve  days  later,  on  being  given  a  slate  and  pencil,  he  wrote 
readily  the  word  'orange,'  and  when  asked  his  name  wrote  it  correctly  with 
the  right  hand,  although  his  mother  asserted  that  she  had  never  previously 
seen  him  do  so.  He  and  four  of  his  brothers  were  left-handed.  About  a 
week  after  this,  being  still  absolutely  speechless,  when  asked  whether  he 
tried  to  speak  and  was  unable,  he  wrote,  '  Yes.'  Asked  if  when  well  he 
wrote  with  his  left  or  right  hand,  he  wrote  '  Both,'  and  then  added,  '  Fight 
with  left.'  In  six  weeks'  time  the  hemiplegia  had  much  diminished,  but  he 
still  never  had  spoken  a  word,  and  continued  to  write  all  his  wishes  on  a 
slate.  His  manner  gave  the  impression  of  a  very  intelligent  and  rather 
facetious  young  man.  At  the  expiration  of  three  months  he  left  the  hos- 
pital, and  when  seen  at  his  home  later  it  was  noted  that  the  boy  repeated 
after  his  mother's  dictation  various  words  and  sentences  with  the  intonation 
of  one  who  endeavors  to  speak  without  moving  the  tongue.  This  power 
gradually  increased  until  he  was  able  to  talk  with  sufficient  distinctness  to 


Morbid  An  atomy  of  Aphasia.  375 

The  clinical  history  of  Bastian's  case  stamps  it  as  one  of 
subcortical  motor  aphasia.  Personally  I  should  have  been 
willing  to  make  the  diagnosis  on  one  fact  alone,  viz.,  the 
patient's  ability  to  write.  I  appreciate,  however,  that 
many  physicians  doubt  the  momentousness  of  this  posses- 
sion as  a  diagnostic  indicator,  and  to  those  it  might  be  said 
that  a  patient  with  cortical  motor  aphasia  of  such  severity 
that  it  causes  absolute  speechlessness,  and  who  is  "  very 
intelligent  and  rather  facetious,"  and  who  passes  through 
the  stammering  stage  in  learning  to  talk,  and  finally  talks 
like  one  whose  tongue  is  fixed  in  the  mouth,  has  yet  to  be 
recorded,  if  the  present  writer's  excursions  afield  into  the 
literature  of  aphasia  have  been  properly  interpreted.  A 
person  to  be  facetious  must  be  in  the  possession  of  inter- 
nal speech  at  least,  and  if  one  of  his  speech  centres  is  de- 
stroyed the  integrity  of  internal  speech  is  destroyed  with 
it.  The  autopsy  record  puts  the  case  in  the  right  light, 
"  a  lesion  in  the  white  substance  beneath  tJic  Rolandic 
area."  That  is  what  the  writer  of  these  pages  means  by 
the  term  subcortical ;  therefore  his  astonishment  that  the 
case  has  been  cited  by  Bastian  in  support  of  the  statement 
that  cortical  motor  aphasia  does  not  entail  agraphia. 

We  are  in  the  early  stages  of  positive  knowledge  con- 
cerning the  exact  limitations  and  seat  of  the  lesions  that 
produce  aphasia,  and  of  the  conclusions  that  can  be  drawn 
from  such  lesions.  If  any  one  thing  is  needed  to  make 
the  data  of  aphasia  more  reliable  in  the  future  and  more 

be  perfectly  understood  by  those  accustomed  to  him.  He  subsequently 
suffered  from  necrosis  of  the  jaw  and  died.  At  the  necropsy  a  large  area 
of  softening  was  found  in  the  right  hemisphere,  involving  part  of  the  white 
substance  beneath  the  Rolandic  area  and  the  island  of  Reil.  The  left 
hemisphere  was  normal." 


376  77*6*  Faculty  of  Speech. 

utilizable  as  scientific  evidence  in  support  of,  or  in  behalf 
of,  certain  theories  of  the  genesis  of  speech  and  its  locali- 
zation, it  is  that  the  patient  be  studied  methodically  and 
carefully,  and  when  the  case  comes  to  autopsy  that  the 
findings  be  recorded  in  definite,  conventional,  and  scien- 
tific language,  particularly  the  seat,  extent,  and  nature  of 
the  lesions  that  are  found,  and  that  there  be  depicted  on  a 
chart  which  represents  the  usual  convolutional  relations 
and  fissuration  of  the  brain  the  seat  and  extent  of  the 
lesion  as  it  manifests  itself  on  the  cortex.  A  study  of 
the  subcortical  lesions,  to  be  of  any  considerable  value, 
must  be  done  with  the  microscope  after  the  tissues  are 
properly  hardened  and  stained. 

In  the  conduct  of  an  autopsy  of  this  kind  a  number  of 
points  are  to  be  noted.  After  the  removal  of  the  calva- 
rium,  the  condition  of  the  pia  should  be  particularly  re- 
marked, as  knowledge  to  be  obtained  from  its  color,  its 
adherence,  and  its  consistence  may  be  of  much  help  in 
interpreting  the  nature  as  well  as  the  duration  of  the 
lesion  in  the  brain,  especially  if  the  lesion  be  of  the 
cortex.  Not  infrequently  aphasic  patients  will  have  a 
complexity  of  symptoms  that  indicates  the  destruction  of 
one  or  more  of  the  speech  centres,  and  yet  before  death 
such  a  patient  may  develop  symptoms  that  are  to  be  ex- 
plained only  by  positing  disease  of  other  parts  of  the 
brain.  Observation  and  study  of  the  macroscopic  appear- 
ances of  the  lesions  in  such  a  case,  their  color,  consistence, 
etc.,  will  allow  us  to  say  with  much  positiveness  that  one 
lesion  is  so  recent  that  it  could  not  have  been  the  cause  of 
symptoms  of  long  standing,  and  that  another  lesion  bears 
the  imprint  of  ancientness,  and  therefore  must  account 


r 

Morbid  Anatomy  of  Aphasia.  377 

for  the  symptoms  of  similar  duration.  To  be  noted,  then, 
are  the  color  of  the  softening,  the  consistence,  the  exact 
location,  particularly  as  contrasted  with  the  undiseased 
hemisphere  of  the  other  side,  the  extent  and  number  of 
the  lesions,  and  the  state  of  the  blood-vessels.  After  this 
the  consistence  of  the  parts  surrounding  the  area  of  soft- 
ening should  be  carefully  determined  in  order  that  one 
may  estimate  how  extensive  the  secondary  changes  are 
which,  though  not  sufficiently  advanced  to  produce  soften- 
ing, may  yet  have  reached  a  pathological  state  that  robs 
the  area  of  its  function. 

It  should  be  particularly  noted  if  the  lesion  limits  itself 
to  areas  of  the  brain  to  which  have  been  allocated  by  phy- 
siologists and  clinicists  special  centres  for  language,  or  if 
a  number  of  such  areas  are  involved,  thus  constituting  the 
anatomical  foundation  of  mixed  or  compound  aphasia. 
After  the  surfaces  of  the  hemispheres  have  been  carefully 
examined  and  any  lesions  found  there  specifically  noted, 
then  the  degree  to  which  such  cortical  lesions  have  ex- 
tended into  the  substance  of  the  brain  and  the  subcortical 
location  and  extent  of  the  lesions  should  be  determined. 
This  is  by  far  the  most  difficult  part  of  the  autopsy.  It  is 
especially  these  subcortical  lesions  that  should  be  most 
carefully  studied,  both  in  their  extent  and  in  their  relation 
to,  and  separation  from,  the  superambient  cortex.  Sev- 
eral cases  of  subcortical  motor  aphasia  have  been  carefully 
studied,  but  the  authors  of  such  studies  have  interpreted 
them  on  the  basis  that  the  symptoms  were  due  to  the 
destruction  of  fibres  of  projection  going  from  the  foot  of 
the  third  frontal  convolution  of  the  left  side;  that  is, 
lesion  of  the  fibres  which  are  described  as  constituting  the 


378  The  Faculty  of  Speech. 

inferior  pediculo-frontal  fascicle.  Now,  if  the  existence  of 
this  fascicle  is  denied,  that  is,  if  the  third  frontal  convolu- 
tion has  no  projection  fibres,  then  the  aphasic  symptoms 
resulting  from  destruction  of  the  parts  of  the  cortex  sub- 
jacent to  it  must  be  explained  in  another  way.  I  believe 
they  can  be  more  convincingly  interpreted  in  a  way  that 
has  already  been  indicated. 

The  differentiation  of  subcortical  motor  aphasia  from 
cortical  motor  aphasia  has  been  most  serviceable  in  widen- 
ing our  conception  and  in  expanding  our  knowledge  of  the 
entire  subject  of  aphasia,  but  much  that  is  desirable  can 
still  be  done  in  this  direction.  The  lesions  accompanying 
subcortical  motor  aphasia  have  been  considered  to  some 
extent  in  the  chapter  on  motor  aphasia,  so  that  it  is  un- 
necessary to  enter  very  fully  into  the  subject  here.  To 
show  the  distance  that  such  lesions  may  be  from  the  cortex 
in  cases  of  clinically  typical  subcortical  motor  aphasia,  I 
may  refer  to  an  instance  published  by  Banti.1  A  man, 
sixty-two  years  old,  who  had  never  been  able  to  read  or 
to  write,  developed  immediately  after  an  attack  of  apo- 
plexy hemiplegia  of  the  right  side  and  inability  to  talk. 
He  understood  questions  that  were  asked  him,  but  when 
he  endeavored  to  respond  the  only  sound  that  came  forth 
was  a  confused  unintelligible  sound  resembling  "  ti — ti— 
ti — ti — ti."  He  died  five  years  after  the  first  attack,  there 
being  in  the  mean  time  no  essential  change  in  his  condi- 
tion. At  the  autopsy  there  was  found  an  apoplectic  cica- 
trix  of  a  brownish-yellow  color  at  the  level  of  the  internal 
capsule  between  the  lenticular  nucleus  and  the  thalamus ; 
that  is,  in  the  anterior  part  of  the  posterior  segment  of  the 
1  Banti :  Loc.  tit. 


Morbid  Anatomy  of  Aphasia.  379 

capsule.  Dejerine1  has  published  an  observation  very 
similar  to  this.  The  patient  was  a  man  sixty-seven  years 
old,  who  had  right-side  hemiplegia  and  aphasia  of  a 
number  of  years'  standing,  and  who  was  absolutely  unable 
to  speak  aloud.  He  could,  however,  whisper  some  words 
that  were  recognizable.  There  was  no  agraphia  or  para- 
graphia.  He  died  eleven  years  after  the  beginning  of  the 
illness,  and'on  autopsy  there  were  found  three  small  foci  of 
softening  situated  in  the  interior  of  the  hemisphere,  one 
in  the  middle  of  the  internal  capsule,  another  in  the 
caudate  nucleus,  and  a  third  in  the  fibres  of  the  white  sub- 
stance subjacent  but  some  distance  removed  from  the  foot 
of  the  third  frontal  convolution.  Although  some  writers, 
such  as  Brissaud,  are  unwilling  to  admit  this  case  to  the 
category  of  true  subcortical  motor  aphasia,  there  would 
not  have  been  any  objection  to  its  admission  if  all  fibres 
coming  from  the  articulatory  areas  of  the  cortex  had  been 
involved. 

The  plan  suggested  by  Dejerine  for  the  conduct  of  the 
autopsy  after  the  superficies  of  the  cortex  has  been  studied 
is  probably  the  most  useful  one,  although  no  hard-and-fast 
rule  can  be  laid  down  for  one's  guidance  in  this  matter. 
Dejerine's  plan  is  the  one  that  was  followed  by  Vialet  and 
Mirallie,  whose  labors  have  done  so  much  to  put  sensory 
aphasia,  cortical  and  subcortical,  on  a  satisfactory  founda- 
tion. The  exact  position  and  extent  of  the  lesions  having 
been  noted,  a  division  of  the  brain  should  be  effected  that 
leaves  the  diseased  region  intact.  The  usual  method  of 
division  is  that  recommended  by  Flechsig,  which  consists 
of  a  horizontal  cut  passing  through  the  head  of  the  cau- 

1  Dejerine  :  Loc.  fit. 


380  Tlie  Faculty  of  Speech. 

date  nucleus  and  the  median  part  of  the  thalamus.  It  is 
done  in  the  following  way  :  After  the  skull  cap  has  been 
sawed  in  the  usual  way  it  is  left  in  place,  and  a  knife 
introduced  between  the  borders  of  the  severed  bone  cuts 
the  brain  horizontally,  en  bloc,  from  without  inward. 
This  method  of  section  facilitates  particularly  study  of  the 
central  masses  and  of  the  internal  capsule.  The  brain  is 
then  hardened  and  a  plaster  cast  taken  of  the  two  pieces 
of  the  hemisphere.  This  gives  an  exact  representation 
of  the  convolutions  and  is  of  the  greatest  service  in 
orienting  one  later  when  the  microscopical  sections  are 
made.  The  further  handling  of  the  tissues  to  render  them 
susceptible  for  coloration  is  the  same  as  that  for  ordinary 
brain  tissue,  and  does  not  call  for  special  description. 
Naturally,  a  special  microtome  is  necessary  to  make  the 
sections,  which  are  cut  horizontally  through  the  length  of 
the  hemisphere,  and  particular  care  is  called  for  in  hand- 
ling these  large  sections.  Mirallie  has  pointed  out  that, 
to  use  the  method  systematically  and  regularly  and  to  get 
the  greatest  service  from  it,  it  is  necessary  to  take  every 
twentieth  or  thirtieth  section  and  make  a  counter-drawing 
of  the  surface  of  the  section  on  a  piece  of  polished  glass. 
This  counter-drawing,  used  in  connection  with  casts  of  the 
cortex  that  have  been  taken,  makes  it  very  easy  to  tell  just 
what  levels  and  what  parts  of  the  cortex  the  various 
numbered  sections  represent. 

The  investigations  that  have  been  carried  out  in  this 
manner  by  Dejerine,  by  Vialet,  Mirallie,  Redlich,  Wyllie, 
and  others  have  been  the  means  of  advancing  our  knowl- 
edge of  sensory  aphasia,  and  especially  of  subcortical 
sensory  aphasia,  to  a  degree  that  is  not  easy  to  overesti- 


Morbid  Anatomy  of  Aphasia.  381 

mate.  In  fact,  it  must  be  said  that  the  reliable  ana- 
tomical data  of  sensory  aphasia  have  come  from  the 
investigators  whose  names  have  just  been  mentioned, 
although  we  do  not  mean  to  say  that  those  of  other 
pathologists  and  clinicians,  such  as  Bastian,  Seguin, 
Uenschen,  Pick,  Wilbrand,  and  others,  are  not  of  the 
greatest  importance. 

The  monograph  of  Vialet  which  appeared  in  1893,  em- 
bodying the  report  of  several  cases  of  sensory  aphasia 
which  the  author  had  studied  personally  and  with  Dejerine, 
marked  an  epoch  in  the  knowledge  not  only  of  the  cere- 
bral centres  of  vision  and  the  intracerebral  visual  mecha- 
nism, but  also  of  sensory  aphasia.  These  cases  and  a  few 
others  which  I  shall  presently  mention  are  of  such  im- 
portance in  exposing  the  pathological  anatomy  of  sensory 
aphasia  that  every  writer  who  essays  to  describe  the  mor- 
bid anatomy  of  aphasia  must  cite  them. 

I  shall  first  refer  to  the  findings  in  one  of  Vialet's 
patients,  in  whom  the  symptom  was  left  homonymous 
hemianopsia,  pure  cortical  hemianopsia.  On  removal  of 
the  brain  an  ancient  spot  of  softening  was  found  in  the 
anterior  one-fourth  of  the  cuneus.  Serial  sections,  made 
in  the  manner  described  above,  showed  that  destruction 
of  tissue  was  very  much  more  extensive  than  the  appear- 
ance of  the  lesion  on  the  cortex  indicated.  The  softening 
involved  the  anterior  two-thirds  of  the  cuneus,  the  an- 
terior part  of  the  calcarine  fissure  and  the  tissue  in  which 
the  parieto-occipital  fissure  pushes  its  way,  and  the  foot 
of  the  cuneus  reaching  as  far  as  the  foot  of  the  hippo- 
campus. In  short,  there  was  softening  of  the  entire  area 
supplied  by  the  anterior  branch  of  the  occipital  artery. 


382  The  Faculty  of  Speech. 

The  consequent  secondary  degeneration  involved  the  optic 
radiations  of  Gratiolet  and  the  interhemispherical  asso- 
ciation fibres  of  the  fibrae  callosae.  The  internal  genicu- 
late  body,  the  thalamus  with  the  exception  of  the  outer 
part  of  the  pulvinar,  the  anterior  quadrigeminal  tubercle, 
and  the  entire  internal  capsule,  as  well  as  the  foot  of  the 
peduncle,  were  entirely  spared. 

In  a  case  of  this  kind  there  was  naturally  no  aphasia, 
and  no  disturbance  of  reading  except  that  conditioned  by 
loss  of  vision.  It  is  for  this  reason  that  I  refer  to  the  case 
here.  The  disability  of  such  a  patient  to  read  is  entirely 
the  same  as  that  which  might  result  from  destruction  of 
one-half  of  the  retina  or  other  peripheral  defect,  and  it  is 
grossly  misleading  to  speak  of  it  as  "  disturbance  of  read- 
ing." 

One  of  the  cases  described  by  Dejerine  and  Vialet  was 
one  of  pure  word  blindness.  The  patient  had  right  homony- 
mous  hemianopsia,  associated  with  inability  to  read  letters 
and  words.  He  could  write  voluntarily  and  from  dicta- 
tion, but  he  could  not  copy  correctly.  The  autopsy 
showed  a  focus  of  softening  evidently  of  long  standing, 
situated  in  the  base  of  the  cuneus  and  the  posterior  por- 
tion of  the  lingual  and  the  fusiform  gyri.  Examination 
of  microscopical  sections  of  the  brain  showed  that  the 
softening  did  not  confine  itself  to  the  cortex,  but  that  it 
could  be  traced  in  the  depths  of  the  white  substance  from 
the  calcarine  fissure  to  the  ependyma  of  the  ventricle, 
where  there  was  complete  destruction  of  the  tapetum,  the 
optic  radiations  of  Gratiolet,  and  the  inferior  longitudinal 
fascicle  at  the  level  of  the  lower  wall  of  the  occipital  horn. 
In  addition,  there  was  found  secondary  degeneration  of 


Morbid  Anatomy  of  Aphasia.  383 

the  radiations  of  Gratiolet,  that  pass  beneath  the  field  of 
Wernicke  in  the  auditory  area. 

Another  case  was  one  of  complete  sensory  aphasia,  the 
patient  being  both  word  blind  and  word  deaf.  The  area 
of  softening  involved  the  posterior  parts  of  the  first  and 
second  temporal  gyri,  the  angular  gyrus,  the  larger  part  of 
the  external  surface  of  the  occipital  lobe,  the  pole  of  the 
lobe  being  spared.  In  this  case  microscopical  examina- 
tion showed  that  not  only  the  cortex  but  the  white  sub- 
stance of  the  parietal  and  occipital  lobes  was  affected. 
The  three  layers  of  fibres  which  border  the  external  sur- 
face of  the  lateral  ventricle  were  degenerated.  The  in- 
ferior longitudinal  fascicle  and  the  optic  radiations  were 
only  partially  destroyed.  In  fact,  the  inferior  longi- 
tudinal fascicle  was  remarkably  well  preserved  in  all  its  in- 
ternal parts  and  in  the  interior  walls  of  the  ventricles.  The 
lesion  destroyed  the  cortex  of  the  posterior  part  of  the  first 
temporal  and  all  the  inferior  parietal,  reaching  as  far  for- 
ward as  the  foot  of  the  ascending  parietal  and  the  pos- 
terior part  of  the  island.  The  posterior  part  of  the  in- 
ternal capsule  from  its  beginning  in  the  lower  part  of  the 
ovale,  as  far  as  the  inferior^part,  was  degenerated.  The 
optic  radiations  were  matted  by  the  first  lesion  to  the  upper 
part  of  the  thalamus,  and  this  seemingly  had  served  to 
preserve  the  integrity  of  these  fibres  at  lower  levels.  In 
contradiction  to  case  three,  this  case  showed  that  the 
anterior  part  of  the  field  of  Wernicke  was  degenerated. 

The  fifth  case  was  one  of  true  sensory  aphasia,  word 
blindness.  On  autopsy  a  spot  of  softening  the  size  of  a 
silver  dollar  was  found  in  the  angular  gyrus.  Microscopi- 
cally it  was  seen  that  the  lesion  began  at  the  point  of  the 


384  The  Faculty  of  Speech. 

ventricle  which  penetrated  the  softened  mass,  and  the  de- 
generation involved  the  bundle  of  the  white  sagittal  sub- 
stance, the  radiations  of  Gratiolet  in  varying  degrees  of 
severity,  the  fibnis  callosre,  and  the  long  occipito-temporal 
association  fibres.  The  two  forceps  were  intact.  The 
fibres  situated  on  the  external  border  of  the  ventricle 
suffered  particularly.  In  the  upper  part  of  the  thalamus 
there  were  two  kinds  of  lesion  :  the  posterior  one  very 
marked,  extended  into  the  zone  of  the  optic  radiations ; 
the  anterior  occupied  the  corona  radiata  at  the  level  of 
the  posterior  part  of  the  thalamus,  the  secondary  degener- 
ation following  along  the  course  of  the  inferior  longi- 
tudinal fascicle  and  the  optic  radiations,  although  the 
tapetum  was  preserved. 

A  communication  concerning  a  case  of  pure  word  blind- 
ness, reported  by  Hoisholt '  as  a  case  of  word  blindness  and 
music  blindness  without  agraphia,  is  accompanied  by  a 
report  of  the  autopsy,  which  shows  how  a  lesion  beginning 
in  the  posterior  pole  of  the  brain  and  producing  symp- 
toms of  subcortical  or  pure  sensory  aphasia  may  extend 
forward  until  it  implicates  some  of  the  speech  centres 
themselves. 

Hoisholt's  patient  was  a  musician,  sixty-three  years  old, 
addicted  to  alcohol.  Entirely  cognizant  of  time  and  place, 
he  was  somewhat  confused  and  his  memory  of  recent 
events  was  impaired.  His  language  was  coherent,  and 
speech  was  normal,  both  in  form  and  arrangement.  The 
intelligence  of  the  man,  and  the  comprehension  of  what 
was  spoken  to  him,  likewise  seemed  to  be  normal.  He 

'Hoisholt:    "  A  Case  of  Pure  Word   Blindness."     Occidental    Medical 
Times,  vol.  vii.,  p.  483,  1893. 


Morbid  Anatomy  of  Aphasia.  385 

was  able  to  spell  words  correctly,  and  also  to  write  properly 
from  dictation  his  name  and  a  number  of  short  English 
words,  but  there  was  an  inability  to  read  what  had  been 
written,  even  his  own  name.  He  would  generally  read 
the  letters  of  the  alphabet  correctly,  but  was  unable  to 
read  the  smallest  words.  The  ability  to  see  and  to  recog- 
nize objects  at  a  distance  was  preserved.  He  played  from 
memory  the  most  difficult  passages  without  a  fault,  but 
when  requested  to  play  by  note  he  tried  to  do  so  and 
failed,  hesitating  and  playing  something  not  before  him. 
He  was  unable  to  name  correctly  any  written  notes. 
There  was  no  trace  of  paralysis.  Hearing  was  impaired 
and  there  was  complaint  of  imperfect  vision.  Careful 
examination  showed  that  there  was  left  homonymous 
hemianopsia.  For  a  time  there  was  some  improvement  in 
his  general  condition,  but  finally  the  visual  defect  became 
more  pronounced,  the  fields  of  vision  becoming  more  and 
more  contracted  until  there  was  total  blindness,  while  the 
pupils  grew  larger  and  failed  to  react  to  light.  Death 
resulted  from  cystitis.  Upon  post-mortem  examination 
the  whole  occipital  lobe  of  the  left  side  of  the  brain  pre- 
sented a  yellowish-green  color,  and,  viewed  from  above, 
appeared  to  be  depressed  below  the  general  level.  The 
convolutions  of  this  area  were  reduced  in  size.  These 
changes  extended  forward  and  upward  as  far  as  the  angu- 
lar and  supramarginal  gyri,  upon  which  they  impinged,  and 
inward  along  the  median  surface  of  the  occipital  lobe,  the 
tip  of  which  was  considerably  softened.  The  posterior  part 
of  the  right  hemisphere  was  of  a  yellowish-red  color,  from 
the  occipital  lobe  upward  and  forward,  a  little  beyond  the 
limits  of  the  change  of  color  upon  the  left  side.  The  con- 
volutions were  flattened,  but  not  so  narrow  or  contracted 
as  those  of  the  opposite  side.  The  cortical  substance 
around  the  posterior  extremity  of  the  temporo-sphenoidal 

25 


386  The  Faculty  of  Speech. 

convolution  (angular  gyrus)  was  somewhat  depressed  below 
the  level  of  the  surrounding  surface,  and  presented  several 
hemorrhagic  spots  varying  in  size  from  that  of  a  pinhead 
to  a  pea,  some  of  them  extending  through  the  whole  thick- 
ness of  the  cortex.  Smaller  hemorrhages  were  also  visi- 
ble on  the  median  surface  of  the  occipital  lobe  in  the 
fusiform  lobule. 

Although  it  is  out  of  place  to  discuss  here  the  clinical 
features  of  this  case  in  relation  to  the  anatomical  lesion, 
it  is  appropriate  to  call  attention  to  the  fact  that  in  the 
beginning  the  lesion  of  the  posterior  cerebral  artery  mani- 
fested its  destructive  effect  in  the  interior  of  the  occipital 
lobe  and  as  the  lesion  extended  posteriorly  and  anteriorly 
it  caused  respectively  true  cortical  anopsia  and  true  word 
blindness. 

A  case  of  sensory  aphasia  reported  by  Dejerine  and 
Mirallie  is  accompanied  by  the  results  of  a  most  carefully 
conducted  autopsy  and  microscopical  examination  of  the 
diseased  focus  and  its  consequent  secondary  degeneration. 
The  patient  had  presented  typical  symptoms  of  sensory 
aphasia,  associated  in  the  beginning  with  right  hemiparesis, 
which  soon  disappeared.  The  course  of  the  disease  was 
attended  with  considerable  amelioration  of  the  word  deaf- 
ness, but  the  complete  alexia,  total  agraphia,  paraphasia, 
and  jargonaphasia  were  very  pronounced  and  remained 
until  the  end.  There  was  no  optic  aphasia  or  mind  blind- 
ness, but  on  account  of  the  difficulty  of  communicating 
with  the  patient  it  had  been  impossible  to  determine  the 
absence  of  hemianopsia. 

The  autopsy  showed  a  lesion  of  the  supramarginal  and 
of  the  angular  gyrus,  and  also  of  the  part  immediately  ad- 


Morbid  Anatomy  of  Aphasia.  387 

jacent  to  the  latter  in  the  inferior  parietal  lobule  of  the 
left  side.  On  microscopical  examination  a  large  focus  of 
softening  was  found  surrounding  the  marginal  fissure  of 
the  island,  and  destruction  of  that  part  of  the  inferior 
parietal  lobule  known  as  the  angular  gyrus.  In  the  white 
substance  of  the  ascending  frontal  convolution  there  were 
three  foci  of  degeneration.  There  was  also  descending, 
retrograde  degeneration  in  the  optic  radiations,  the  inferior 
longitudinal  fascicle,  the  pulvinar,  the  external  geniculate 
body,  and  of  the  internal  capsule  and  the  foot  of  the 
peduncle. 

In  this  case  the  three  distinct  and  primitive  foci  were : 
i.  A  focus,  by  far  the  most  important,  situated  in  the 
posterior  marginal  fissure  of  the  island,  which  had  severed 
the  base  of  the  inferior  parietal  convolution  just  at  the 
point  of  junction  with  the  island.  This  focus  comprised 
all  the  supramarginal  gyrus,  and  destroyed  the  white  fibres 
of  this  convolution  and  the  cortex  as  far  forward  as  the 
fissure  of  Sylvius.  2.  A  focus  of  softening  occupying  the 
base  of  the  Rolandic  operculum  at  a  point  where  it  is 
continuous  with  the  island.  3.  A  focus  measuring  only  a 
few  millimetres  in  diameter,  just  at  the  crest  of  the 
angular  gyrus,  and  which  caused  a  degeneration  very 
strictly  confined  in  the  middle  part  of  the  white  substance 
of  this  convolution.  These  foci  had  each  caused  secon- 
dary degenerations,  the  principal  one  of  which  had  sev- 
ered completely  the  retrolenticular  segment  of  the  internal 
capsule,  the  radiations  of  the  thalamus,  and  the  inferior 
longitudinal  fascicle.  Behind  this  point  the  degeneration 
followed  the  external  face  of  the  lateral  ventricle  and 
reached  to  the  occipital  lobe.  The  fibres  of  the  corpus 


388  The  Faculty  of  Speech. 

callosum  which  turn  about  the  posterior  extremity  of  the 
lateral  ventricle  were  degenerated,  forming  at  this  level  a 
zone  of  translucent  fibres,  standing  out  in  contrast  to  the 
normal  fibres  of  the  corpus  callosum.  Anteriorly  the  de- 
generation penetrated  the  posterior  part  of  the  thalamus. 
The  pulvinar  was  much  atrophied,  and  its  radiating  fibres 
had,  disappeared.  The  external  geniculate  body  and  the 
white  fibres  surrounding  it  showed  slight  departures  from 
normal. 

In  this  case,  the  original  lesion  occupying  the  posterior 
marginal  fissure  of  the  island  had  separated  the  angular 
gyms  and  all  its  connections  from  the  zone  of  language. 
Although  the  visual  images  of  words  which  are  stored  in 
the  angular  gyrus  were  in  a  measure  preserved,  they  were 
no  longer  accessible  to  the  zone  of  language,  and  this  iso- 
lation of  the  angular  gyrus  had  caused  from  the  standpoint 
of  its  function  bearing  on  internal  language  the  same  re- 
sults as  a  direct  lesion  of  the  centre  for  the  visual  images 
and  words  would  have.  Mirallie,  in  reporting  the  case, 
says  very  truthfully  that  this  is  the  first  time  that  a  case 
of  this  kind  had  been  studied  microscopically,  and  the 
scientific  accuracy  with  which  the  lesion  and  its  subse- 
quent secondary  degeneration  were  depicted  allows  of  true 
interpretation  of  the  symptoms  of  the  case,  for  without 
such  microscopic  examination  the  totality  of  the  symptoms 
would  have  been  much  less  intelligible.  The  anatomical 
findings  in  a  case  of  sensory  aphasia  under  personal  obser- 
vation have  been  detailed  in  connection  with  the  history 
of  the  case,  and  need  not  be  repeated  here. 

The  morbid  anatomy  of  a  case  of  subcortical  sensory 
aphasia  of  the  verbal  type  (pure  verbal  blindness  of  De- 


Morbid  Anatomy  of  Aphasia.  389 

jerine,  subcortical  alexia  of  many  writers)  has  recently 
been  studied  with  great  care  by  Redlich.  The  patient, 
a  sixty-four-year-old  man,  had  had  for  a  considerable  time 
loss  of  visual  acuteness,  dependent  upon  optic  atrophy,  but 
this  did  not  prevent  him  from  discharging  the  duties  of 
a  scrivener.  Later  he  developed  a  right-side  motor  and 
sensory  hemiparesis,  right-side  hemianopsia,  and  word 
blindness.  The  hemiparesis  was  transitory.  After  the 
first  fleeting  disturbances  following  the  shock  there  was 
total  literal  and  verbal  alexia,  but  no  mind  blindness. 
Writing  was  undisturbed,  both  voluntarily  and  from  dic- 
tation. 

At  the  autopsy  there  was  found  a  spot  of  softening  in 
the  left  occipital  lobe  immediately  around  the  calcarine 
fissure  in  the  lingual  and  fusiform  lobules,  extending  as 
far  forward  in  the  medullary  substance  as  the  posterior 
horn  of  the  ventricle.  The  splenium  of  the  corpus  cal- 
losum,  the  posterior  part  of  the  thalamus,  and  the  tail  of 
the  caudate  nucleus  were  softened.  Microscopical  exami- 
nation showed  destruction  of  all  the  optic  radiations ;  and 
the  forceps  major  as  well  as  a  part  of  the  forceps  minor 
were  degenerated.  The  inferior  longitudinal  fascicle  was 
also  the  seat  of  degeneration.  The  cortex  of  the  angular 
gyrus  was  entirely  intact.  The  left  fornix,  the  anterior 
portion  of  the  cornu  ammonis,  and  the  tapetum  showed 
some  spots  of  softening,  which,  according  to  Redlich,  had 
interrupted  the  connection  between  the  right  visual  area 
and  the  left  visual  centre,  the  author  believing  with  H. 
Sachs  that  this  pathway  is  through  the  tapetum.  On  ac- 
count of  the  interruption  of  the  inferior  longitudinal 
fascicle,  the  connection  between  the  left  visual  centre  and 


390  The  Faculty  of  Speech. 

the  zone  of  language  was  interrupted.  This  case  is  in 
reality  one  of  the  most  important  that  have  yet  been  con- 
tributed to  the  fund  of  exact  knowledge  concerning  the 
pathology  of  aphasia,  and  although  its  reporter  draws  what 
I  believe  to  be  some  unwarrantable  inferences,  which  are 
criticised  in  the  chapter  on  "  Sensory  Aphasia,"  particularly 
concerning  the  neural  basis  of  writing,  it  nevertheless  puts 
beyond  doubt  the  existence  of  this  form  of  aphasia. 
Redlich  is  of  the  opinion  that  cases  of  this  kind  would  be 
better  designated  by  the  term  intercortical  aphasia  than 
subcortical. 

There  are  a  number  of  other  observations  that  have 
been  of  great  importance  in  corroborating  the  conclusions 
of  Dejerine  and  his  pupils  in  regard  to  sensory  aphasia. 
Wyllie  has  published  the  report  and  autopsy  findings  of 
a  patient  with  subcortical  visual  aphasia,  the  two  promi- 
nent symptoms  having  been  word  blindness  and  homony- 
mous  hemianopsia.  The  lesion  was  found  to  be  a  soft- 
ening of  the  white  matter  in  the  floor  of  the  posterior  horn 
of  the  left  lateral  ventricle.  It  was  due  apparently  to  oc- 
clusion of  one  of  the  branches  of  the  posterior  cerebral 
artery.  The  softening  confined  itself  strictly  to  the  white 
matter,  and,  though  the  gray  substance  of  the  convolutions 
immediately  over  it  was  in  a  somewhat  sunken  and 
atrophied  state,  there  could  be  no  doubt  that  this  was 
merely  a  condition  consequent  to  the  destruction  of  tissues 
underneath. 

Examination  of  the  sections  of  the  brain  showed  that 
the  atrophy  extended  from  the  tip  of  the  under  surface  of 
the  occipital  lobe,  where  the  dilated  posterior  horn  of  the 
ventricle  reached  to  within  an  eighth  of  an  inch  of  the  sur- 


Morbid  Anatomy  of  Aphasia.  391 

face  forward  as  far  as  the  middle  of  the  crus  cerebri. 
That  is  to  say,  the  convolutions  affected  were  the  lingual 
and  fusiform,  together  with  the  posterior  half  of  the  gyrus 
hippocampus.  There  was  no  involvement  of  the  angular 
gyrus.  In  this  case  the  disease  of  the  white  matter  of  the 
occipital  lobe  had  involved  the  fibres  connecting  the  an- 
gular convolution  with  the  right  and  left  primary  visual 
areas,  thus  causing  word  blindness ;  and  on  account  of  the 
interruptions  of  the  radiations  of  Gratiolet  from  the  pri- 
mary centre  for  vision  in  the  left  occipital  lobe  there 
resulted  hemianopsia. 

A  second  case  recorded  by  the  same  writer  is  no  less 
interesting.  A  man  seventy  years  old  developed  a  slight 
motor  and  sensory  hemiplegia  with  well-marked  right 
lateral  homonymous  hemianopsia.  The  hemiplegia  soon 
almost  completely  disappeared,  but  the  hemianopsia  and 
total  word  blindness  continued.  There  were  a  slight  de- 
gree of  word  deafness  and  amnesia  of  nouns.  At  the 
autopsy  the  zone  of  language  macroscopically  was  entirely 
normal.  The  chief  morbid  appearances  were  found  on 
the  under  surface  of  the  occipital  lobe,  involving  princi- 
pally the  fourth  temporal  lobe,  bordering  the  occipital  con- 
volution, the  hippocampal  convolution,  the  lingual  con- 
volution, the  anterior  part  of  the  cuneus,  and  the  calcarine 
fissure.  On  section  of  the  brain,  it  was  seen  that  beneath 
the  thin  cortex  there  was  such  marked  atrophy  of  the 
white  matter  that  the  cortex  was  in  direct  connection  with 
the  ependyma  of  the  ventricular  horn.  At  this  region  of 
greatest  atrophy,  i.e.,  the  under  surface  of  the  occipital 
lobe,  about  the  middle  of  the  inferior  temporal  occipital 
or  the  fourth  temporal  convolution,  there  was  a  marked 


392  The  Faculty  of  Speech. 

depression  on  the  surface  of  the  brain  about  two  inches 
in  length  and  an  inch  in  breadth.  This  depression  marked 
the  situation  of  a  cyst-like  cavity  where  the  gray  matter 
and  the  subjacent  white  matter  had  been  almost  entirely 
destroyed. 

Serieux  has  recorded  a  case  of  word  blindness  with 
agraphia  caused  by  destruction  of  the  angular  gyrus,  and, 
although  the  report  is  not  accompanied  by  the  details  of 
a  microscopical  examination,  the  strictness  with  which  the 
lesion  was  confined  to  the  inferior  parietal  lobule  makes 
it  a  very  important  and  valuable  case,  more,  however, 
as  substantiating  the  allotted  function  of  the  angular 
gyrus  than  as  a  contribution  to  the  morbid  anatomy  of 
aphasia. 

The  same  writer  has  also  published  a  detailed  account 
of  a  case  of  mind  blindness  associated  with  word  blind- 
ness. The  patient,  a  woman,  sixty-two  years  old,  had  a 
stroke  followed  by  transient  paralysis,  word  blindness,  and 
agraphia,  mind  blindness,  word  deafness,  and  paraphasia. 
The  patient's  condition  had  bettered  somewhat,  when  she 
died  suddenly  from  an  intercurrent  pneumonia.  Unfor- 
tunately, the  lesions  in  the  brain  were  multiple,  there 
being  oh  the  left  side  a  softening  in  the  inferior  parietal 
and  also  a  limited  focus  of  softening  in  the  posterior  ex- 
tremity of  the  first  and  second  temporal  convolutions.  On 
the  right  side  of  the  brain  a  softening,  somewhat  more 
extensive,  was  found  in  practically  the  same  areas. 

A  very  similar  observation  to  this  has  been  communi- 
cated by  Bruns,1  except  in  this  case  the  clinical  phenomena 

1  Bruns :  Neurologisches  Centralblatt,  Nos.  17  and  18,  1888;  Nos.  i 
and  2,  1894. 


Morbid  Anatomy  of  Aphasia.  393 

were  those  characteristic  of  complete  sensory  aphasia,  with 
right  homonymous  hemianopsia.  The  autopsy  showed 
that  the  greater  part  of  the  white  substance  of  the  first  tem- 
poral convolution  and  the  adjacent  parietal  convolution 
were  in  a  state  of  advanced  softening. 

There  are  few  better  cases  to  illustrate'  the  lesions  of 
sensory  aphasia,  type  of  word  deafness,  than  a  case  pub- 
lished by  Leva.1  The  symptoms  pointed  most  unerringly 
to  a  lesion  of  the  auditory  centre,  and  on  autopsy  there 
was  found  a  yellowish,  fluctuating  sunken-in  area  of  soft- 
ening in  the  middle  segment  of  the  left  upper  temporal 
convolution  and  almost  exactly  two  millimetres  from  the 
upper  border  of  the  second  temporal  convolution.  The 
softening  was  found  to  be  a  cyst  rilled  with  milky,  cloudy 
fluid.  It  measured  in  every  diameter  about  three  centi- 
metres. Anteriorly  it  extended  to  one  centimetre  from 
the  tip  of  the  first  frontal  gyms  and  posteriorly  to  two 
centimetres  from  the  posterior  end  of  the  same  gyrus. 
Internally  it  approached  the  two  external  segments  of 
the  lenticular  nucleus.  In  the  second  frontal  convolu- 
tion of  the  left  side  there  was  another  small  focus  of 
softening. 

Although  there  are  on  record  many  cases  of  aphasia  ac- 
companied with  more  or  less  autopsical  details,  I  shall  have 
to  content  myself  with  the  relation  of  one  more  case  taken 
from  the  literature,  and  that  a  case  of  subcortical  word 
deafness,  published  by  Pick.  The  patient  was  a  typical 
case  clinically.  She  could  understand  neither  spoken 

1  Leva  :  "  Localisation  der  Aphasien."  Arch.  f.  path.  Anat.  und  Phys. 
und  f.  klin.  Med..  Berlin,  Mai,  Bd.  cxxxii.  (Folge  xiii.,  Bd.  ii.),  H.  2, 
p.  333,  1893. 


394  The  Faculty  of  Speech, 

speech  nor  melodies.  On  removal  of  the  brain,  no  de- 
parture from  normal  could  be  made  out  save  that  the  con- 
volutions seemed  to  be  a  little  sunken.  Examination  of 
the  superior  gyri  of  the  temporal  lobes  showed  that  they 
were  somewhat  abnormal  in  consistence  and  color.  On 
the  right  side  the  first  temporal  and  a  large  part  of  the 
second  temporal,  the  island  of  Reil,  and  the  adjacent  parts 
of  the  anterior  central  convolution  and  of  the  inferior  frontal 
convolution  were  transformed  into  a  whitish-yellow  firm 
mass.  The  environment  of  these  softened  parts  was  more 
dense.  The  lateral  ventricle  of  this  side  was  slightly  dis- 
tended and  contained  some  yellow  serum.  Section  of  this 
hemisphere  made  after  the  plan  of  Pitres  showed  that  the 
cortex  of  the  affected  convolutions  and  the  white  substance 
were  the  seat  of  yellow  softening.  This  softening  com- 
prised, in  a  section  made  through  the  ascending  frontal 
convolution,  the  region  just  in  front  of  the  external  cap- 
sule and  most  external  part  of  the  lenticular  nucleus. 
The  globus  pallidus  and  the  internal  capsule  were  intact. 
In  the  left  hemisphere  the  posterior  part  of  the  first  tem- 
poral convolution  and  the  supramarginal  gyrus  were 
softened,  the  same  as  on  the  right  side.  Frontal  sections 
of  this  hemisphere  showed  that  the  softening  was  super- 
ficial and  affected  no  part  of  the  external  capsule  or  the 
central  nuclei.  The  island  of  Reil  was  intact.  The 
softened  areas  in  this  hemisphere  had  a  more  gelatinous 
aspect  and  the  substance  of  the  adjoining  convolutions 
was  firmer.  On  account  of  the  meagreness  of  the  ana- 
tomical details  in  this  case,  and  on  account  of  the  exten- 
siveness  of  the  lesion,  it  bears  only  indirect  testimony  in 
behalf  of  the  exact  localization  of  the  aphasia  lesions. 


Morbid  Anatomy  of  Aphasia.  395 

In  a  word,  the  pathology  of  true  aphasia  is  the  pathology 
of  a  lesion  that  injures  the  zone  of  language,  and  of  sub- 
cortical  aphasia  a  lesion  of  the  immediate  incoming  and 
outgoing  pathways  by  virtue  of  whose  integrity  the  speech 
centres  manifest  their  function. 


CHAPTER    XI. 
REMARKS  ON  THE  TREATMENT  OF  APHASIA. 

I  SHALL  discuss  the  treatment  of  aphasia  very  briefly, 
from  the  standpoint  of  the  physician  and  surgeon,  and 
from  the  pedagogue's  point  of  view. 

Unhappily  neither  the  physician  nor  the  pedagogue  can 
be  of  considerable  assistance  to  the  vast  majority  of  aphasic 
patients.  The  medicinal  treatment  depends  entirely  upon 
the  nature  of  the  lesion  that  causes  the  aphasic  symptom 
complex.  If  the  lesion  be  a  focus  of  encephalomalacia,  then 
all  that  can  be  expected  of  medicinal  treatment  is  to  assist 
nature  to  prevent  further  destruction  of  tissue,  and  par- 
ticularly to  assist  in  preventing  a  repetition  of  the  imme- 
diate exciting  cause  of  the  softening.  On  the  other  hand 
if  the  lesion  be  a  gummatous  meningitis,  or  an  isolated 
gummatous  formation,  in  the  zone  of  language  or  the  sub- 
cortical  speech  tracts,  and  these  can  be  diagnosticated  as 
such,  medicinal  treatment  is  of  the  greatest  value.  A 
case  of  sensory  aphasia  recorded  by  Bramwell  and  cited 
in  another  chapter  is  in  evidence.  This  patient  had  the 
profoundest  symptoms  of  sensory  aphasia,  yet  'she  fully 
recovered  under  the  influence  of  antisyphilitic  medica- 
tion. Another  case  in  which  the  results  of  antisyphilitic 
treatment  were  most  gratifying,  even  though  the  symp- 
toms did  not  completely  yield  to  medication,  has  very 


Remarks  on  the   Treatment  of  Aphasia.    397 

recently  been  published  by  Mantle.1  The  difficulty  in 
cases  of  this  kind  is  oftenest  with  the  etiological  diagnosis. 
Usually  the  patient  is  not  in  condition  to  vouchsafe  any 
information  concerning  himself,  and  as  his  family  is,  as 
a  rule,  ignorant  of  such  matters,  the  physician  is  compelled 
often,  if  he  has  not  been  familiar  with  the  patient's  his- 
tory, to  make  a  diagnosis  of  previous  syphilitic  infection 
on  less  satisfactory  data  than  are  ordinarily  considered  es- 
sential. Personally  I  am  inclined  to  suspect  a  luetic 
origin  in  every  case  of  aphasia  coming  on  abruptly  that 
occurs  before  the  fifth  decade  of  life,  when  valvular  trouble 
of  the  heart,  the^rjeeeTTf^possession  of  acute  disease,  and 
injury  can  be  excluded. 

It  would  be  a  work  of  supererogation  to  repeat  in  detail 
the  treatment  applicable  to  the  different  forms  of  aphasia, 
for  it  will  occur  to  every  one  who  has  in  mind  the  various 
causes  of  aphasia.  The  treatment  for  aphasia  in  one  pa- 
tient may  be  just  as  different  from  the  treatment  appli- 
cable to  the  next  one  as  the  causes  are  different.  For  in- 
stance, in  the  beginning  the  treatment  of  a  uraemic  patient 
is  venesection  if  the  patient  has  not  an  organic  form  of 
renal  disease ;  yet  this  kind  of  treatment  would  be  fatal 
to  a  patient  whose  aphasia  was  dependent  upon  autoch- 
thonic  thrombosis. 

When  aphasic  symptoms  develop  slowly  without  fever 
and  with  symptoms  of  increasing  intracranial  irritation  and 
pressure,  then  tumor  and  abscess  must  be  thought  of.  In 
making  the  diagnosis  and  the  differentiating  diagnosis  one 
must  be  guided  by  the  general  rules  applicable  to  the 
solution  of  these  problems.  When  there  are  grounds  for 

1  Mantle  :  British  Medical  Journal,  February  6th,  1897,  p.  325. 


398  The  Faculty  of  Speech. 

the  belief  that  the  lesion  is  of  a  luetic  nature,  then  the  ad- 
ministration of  mercury  and  iodide  of  potassium  cannot 
be  carried  out  with  too  great  promptness  and  attention. 
Syphilitic  lesions  that  develop  some  years  after  the  pri- 
mary infection  are,  it  is  universally  conceded,  more 
amenable  to  the  iodide  of  potassium  than  to  all  other 
measures  combined.  If,  however,  the  date  of  the  primary 
lesion  is  not  very  remote,  then  the  administration  of  iodide 
should  be  simultaneous  with  the  mercury,  or  the  one 
should  follow  the  other  in  the  shape  of  a  course  of  the 
ope  and  then  of  the  other. 

The  treatment  of  aphasia  dependent  upon  organic  dis- 
ease such  as  tumor,  abscess,  purulent  meningitis,  and  focal 
disease  of  any  nature,  does  not  differ  from  the  treatment 
of  these  conditions  when  aphasia  is  not  present.  When 
their  presence  is  attended  by  symptoms  which  seem  to 
indicate  that  they  are  amenable  to  surgical  treatment 
their  removal  should  not  be  delayed.  In  fact,  the 
aphasia  is  oftentimes  the  localizing  symptom  that 
makes  diagnosis  positive  and  operation  possible.  The 
case  which  I  have  cited  of  Zaufal  and  Pick,  an  abscess 
of  the  brain  successfully  treated  by  operation,  is  in 
evidence. 

To  enumerate  the  symptoms  caused  by  focal,  cortical,  or 
subcortical  disease  that  may  cause  aphasia  would  be  a 
repetition  of  much  that  has  been  said  in  the  chapter  on 
"  Diagnosis,"  and  elsewhere.  The  seemingly  widespread 
belief  that  aphasia  is  almost  exclusively  an  on-hanger  of  the 
apoplectic  state  seems  to  necessitate,  however,  emphasizing 
the  fact  that  some  manifestations  of  the  complexity  of 
symptoms  constituting  aphasia  are  of  great  diagnostic  im- 


Remarks  o?t  the   Treatment  of  Aphasia.   399 

portance  in  nearly  every  disease  affecting  the  brain.  It  is 
a  common  symptom  in  the  recently  recognized  and  de- 
scribed disease  acute  hemorrhagic  encephalitis ;  it  is  per- 
haps the  most  constant  symptom  of  abscess  of  the  brain,  on 
account  of  the  pathogenetic  relationship  of  disease  of  the 
middle  ear  and  cerebral  abscess,  and  it  is  not  uncommon 
at  some  stage  in  the  career  of  general  paresis  and  of  mul- 
tiple, insular,  and  diffuse  cerebral  sclerosis;  while  its 
occurrence  after  injury  which  may  cause  localized  inflam- 
mation of  the  meninges  or  of  the  brain  itself,  hemor- 
rhage, depression  of  bone  and  spicules,  is  not  unusual. 
Naturally,  in  order  to  produce  aphasia,  these  factors 
must  manifest  their  injurious  activity  on  the  speech 
centres,  their  interconnections,  projections,  or  the  imme- 
diate pathways  leading  to  them ;  to  be  less  specific,  on 
the  left  hemisphere  in  right-handed  persons  and  vice 
versa.  The  form  of  aphasia  that  any  of  these  diseases  and 
accidents  may  cause  will  depend  upon  the  location  of  the 
lesion  and  not  on  its  nature.  The  only  variety  dependent 
upon  any  of  the  above-enumerated  conditions  that  is  very 
uncommon  is  the  subcortical  form  of  motor  aphasia ;  while 
the  subcortical  sensory  variety  is  correspondingly  frequent. 
This  is  readily  understood,  if  we  recall  that  the  part  of  the 
brain  which  must  be  diseased  to  cause  subcortical  motor 
aphasia  is  well  protected  from  injury  and  has  no  par- 
ticular relationship  to  the  important  factors  that  condition 
abscess  of  the  brain. 

Oftentimes  a  careful  consideration  of  the  symptom 
aphasia  in  these  diseases  will  be  the  most  important  factor 
in  determining  whether  or  not  an  operation  shall  be  done, 
i.e.,  whether  the  lesion  is  sufficiently  localizable  to  warrant 


400  The  Faculty  of  Speech. 

advising  the  surgeon  to  trepan  the  skull  and  attempt  to 
remove  the  materies  morbi. 

Taking  it  all  in  all,  the  question  of  the  medicinal  treat- 
ment of  aphasia  never  comes  up  for  consideration.  The 
question  that  does  present  is  :  How  shall  we  treat  the  con- 
dition of  which  aphasia  is  the  symptom  ?  To  answer  that 
question  satisfactorily  requires  an  intimate  knowledge  of  the 
therapeusis  of  all  the  diseases,  functional  and  organic,  that 
have  been  enumerated  in  the  chapter  on  "  Etiology"  with 
which  aphasia  may  be  associated.  Treatment  may  consist 
of  such  a  simple  matter  as  the  interdiction  of  alcohol  in  a 
case  of  toxic  dyslexia,  or  it  may  require  the  combined 
skill  of  the  physician  and  surgeon  to  diagnosticate  and  re- 
move an  abscess  or  tumor.  The  treatment  of  the  dynamic 
aphasias  is  a  different  matter  from  the  treatment  of  the 
organic  aphasias.  In  the  former  all  that  is  necessary  is  to 
remove  the  cause  and  the  symptom  will  disappear,  while  in 
the  latter  the  cause  may  be  removed  and  the  pathological 
condition  which  it  has  excited  still  continues  and  with  it 
the  aphasia. 

The  pedagogical  treatment  of  aphasia  is  a  matter  of  re- 
cent development.  It  has  been  the  legitimate  result  of  an 
inquiry  into  the  physiological  and  psychological  antece- 
dents of  articulate  speech,  and  of  clinical  observations  that 
when  a  young  person  became  aphasic,  even  though  the 
lesion  was  a  very  severe  and  extensive  one,  the  faculty  of 
speech  was  restored  to  him.  Moreover,  almost  from  the 
very  beginning  of  the  history  of  aphasia,  it  has  been 
recognized  that,  even  when  the  so-called  "  speech  centre," 
meaning  Broca's  area,  was  completely  destroyed,  the  patient 
regained  occasionally  some  capacity  to  speak  individual 


Remarks  on  the    Treatment  of  Aphasia.   401 

words  or  a  number  of  words.  Various  hypotheses  have 
been  formulated  to  explain  these  occurrences,  the  most 
widely  accepted  apparently  being  that  of  Jackson,  who 
suggested  twenty  years  ago  that  the  "  uneducated  centre" 
of  the  opposite  side  is  in  a  way  related  to  conventional, 
emotional,  and  other  forms  of  what  he  terms  "  degraded" 
speech,  in  contradistinction  to  intellectual  speech.  This 
is  the  theory  accepted  by  many  writers  to-day.  Recently 
Wyllie  has  framed  a  theory  along  somewhat  the  same  lines 
on  the  "  overflow  of  education  into  the  opposite  hemi- 
sphere;" the  hemisphere  that  contains  the  zone  of  lan- 
guage takes  up  all  that  it  can  in  the  way  of  education,  and 
that  which  it  is  not  equal  to  taking  up  flows  over  into  the 
other  hemisphere.  As  I  have  said  in  a  previous  chapter, 
the  entire  subject  of  the  repossession  of  the  speech  faculty 
in  patients  in  whom  it  has  been  lost  must  needs  be  looked 
at  to-day  from  another  standpoint  than  it  was  a  few 
years  ago,  when  the  various  forms  of  subcortical  aphasia 
had  not  been  satisfactorily  differentiated.  It  seems  to  me 
that  in  the  light  of  our  present  knowledge  of  aphasia  it 
must  be  granted  that  not  only  do  the  areas  of  the  opposite 
hemisphere  sometimes  under  the  stress  of  education  un- 
dertake, in  a  very  incomplete  way,  the  speech  function  of 
the  destroyed  area  of  the  hemisphere  phylogenetically  and 
ontogenetically  prepared  to  carry  on  the  speech  faculty,  but 
that  the  immediate  environmental  areas  of  the  speech 
centres  of  the  left  hemisphere  may  take  up  the  function  in 
part ;  secondly,  that  the  opposite  hemisphere,  the  one  that 
has  the  zone  of  language  ontogenetically  developed,  is  not  an 
uneducated  hemisphere  at  all,  but  that  it  is  in  one  sense 
just  as  much  educated  as  the  hemisphere  in  which  the 
26 


4O2  The  Faculty  of  Speech. 

zone  of  language  is  situated.  It  must  needs  be  admitted 
that  there  are  a  general  auditory  area,  a  general  visual  area, 
and  a  general  kinaesthetic  area  in  the  right  hemisphere  as 
well  as  in  the  left  hemisphere,  and  that  in-coming  stimuli 
make  a  similar  impression  on  it  as  they  do  on  the  so-called 
"  educated"  hemisphere.  These  impressions  are  bilateral 
in  reception  but  unilateral  in  interpretation.  This  uni- 
laterality  of  interpretation  is  determined  by  commissural 
fibres  of  the  corpus  callosum.  Now  the  same  factors 
that  determine  right-handedness  determine  also  that  the 
left  hemisphere  shall  be  the  executive  speech  side,  but  the 
elementary  work  is  done  on  both  sides.  It  seems  to  me 
that  so  far  every  one  who  is  willing  to  accept  the  sugges- 
tions of  experimental  physiology  must  go.  How  many  are 
willing  to  admit  that  the  execution  of  speech  is  an  auto- 
matic act  and  requires  no  conscious  preparation,  if  process 
of  anatomical  completion  is  not  considered  "  preparation," 
is  another  matter.  Those  who  believe  that  the  execution 
of  speech  is  an  automatic  act  find  it  easier  to  explain  how 
an  approach  to  or  an  unfinished  automatism  can  be  as- 
sumed by  the  opposite  hemipshere  which  is  educated  but 
which  is  not  intended  to  be  automatic,  and  especially  in 
young  children,  in  whom  the  habit  of  automatic  activity 
has  not  become  fixed  by  continued  practice.  I  do  not 
think  it  at  all  improbable  that  if  a  healthy  child  should 
be  kept  mute  until  it  was  from  five  to  six  years  of  age, 
that  is,  until  such  a  time  as  the  neuro-muscular  appa- 
ratus subserving  speech  was  fully  developed,  he  would  go 
through  the  lalling  and  other  stages  of  speech  imperfec- 
tions as  do  children  who  begin  "  to  learn"  to  talk  be- 
fore the  executive  parts  are  fully  developed.  The  words 


Remarks  on  the    Treatment  of  Aphasia.   403 

that  such  a  child  used  (which  would,  of  course,  depend 
upon  the  words  that  he  had  heard)  might,  I  believe,  be 
perfectly  formed.  In  other  words,  the  execution  of  speech 
would  be  as  automatic  as  breathing,  and  that  in  mankind 
speech  is  an  endowment  more  than  an  acquirement. 
Furthermore,  the  factors  that  determine  the  seat  of  this 
automatic  activity  are  the  conditions  that  we  have  here- 
tofore supposed  determined  the  education  of  the  left 
hemisphere. 

A  most  remarkable  case  bearing  on  this  matter  has  re- 
cently been  published  by  Bastian.  The  patient  was  a  boy, 
twelve  years  old,  who  had  been  subject  to  epileptic  fits  at 
intervals.  The  first  of  these  occurred  in  infancy,  when 
the  patient  was  about  nine  months  old.  Toward  the  end  of 
the  second  year  the  fits  seemed  to  have  ceased.  The  hear- 
ing was  good  and  the  child  appeared  to  be  of  average  intelli- 
gence— to  be  well,  in  fact,  in  all  respects,  except  that  he  did 
not  talk.  When  nearly  five  years  old  the  little  fellow  had 
not  spoken  a  single  word,  and  about  this  time  two  eminent 
physicians  were  consulted  in  regard  to  his  "  dumbness." 
But  before  the  expiration  of  another  twelve  months,  on  the 
occasion  of  an  accident  happening  to  a  favorite  toy,  he 
suddenly  exclaimed,  "  What  a  pity !"  although  he  had 
never  previously  spoken  a  word.  The  same  words  could 
not  be  repeated,  nor  were  others  spoken,  notwithstanding 
all  entreaties,  for  a  period  of  two  weeks.  Thereafter  the 
boy  progressed  rapidly  and  speedily  became  most  talkative, 
and  spoke  without  the  least  sign  of  impediment  or  defect. 

One  other  point  that  has  previously  been  mentioned.  A 
number  of  the  cases  that  have  been  reported  to  show  the 
assumption  of  speech  function  by  the  opposite  hemisphere 


404  The  Faculty  of  Speech. 

have,  I  hope,  been  conclusively  shown  to  be  dependent  upon 
a  subcortical  lesion  and  not  upon  destruction  of  a  speech 
centre,  and  the  partial  or  complete  recovery  of  speech  was 
commensurate  with  a  disappearance  of  the  conditions  that 
had  determined  the  partial  interruption  of  the  conducting 
fibres.  In  these  cases  recovery  of  speech  has  gone  on  pari 
passu  with  disappearance  of  other  symptoms,  such  as  hemi- 
plegia,  for  instance.  In  other  cases  in  which  the  lesion - 
has  been  of  the  speech  centres  the  partial  repossession  of 
speech  has  been  due  to  the  fact  that  the  entire  speech 
centre,  which  in  the  beginning  of  an  aphasic  attack  was 
completely  overthrown,  has  in  a  slight  measure  righted  it- 
self after  the  exudative  and -occlusive  conditions  have  sub- 
sided. Then  the  patient  finds  himself  in  possession,  to  a 
very  insignificant  degree,  of  his  previous  speech  endow- 
ment. In  other  cases  there  can  be  no  question  that  the 
educated  areas  of  the  other  hemisphere  develop  some  ex- 
ecutive capacity.  This  is  determined  artificially,  i.e.,  by 
education,  and  not  ontogenetically  as  it  is  normally,  except 
tp-the  very  slightest  degree. 

\In^  brief,  then,  the  education  of  an  aphasic  patient 
should  consist  in  endeavoring  to  cause  the  centre  or  cen- 
tres in  the  left  side  of  the  brain  that  are  not  destroyed 
by  the  lesion  which  causes  the  aphasia  to  take  the  in- 
itiative in  the  primary  recall  of  words,  and  complete  the 
"  circuit"  necessary  for  speech  by  forcing  the  educated 
opposite  side  to  supply  a  centre  similar  to  that  which  has 
been  destroyed^  For  example,  if  the  articulatory  kinaes- 
thetic  centre  is  detroyed,  the  primary  revival  of  the  word 
that  should  be  spoken  is  through  the  auditory  centre,  and 
this  calls  up  in  temporal  coincidence  or  succession  the 


Remarks  on  the    Treatment  of  Aphasia.  405 

visual  and  the  articulatory  centres.  The  articulatory  cen- 
tre, being  destroyed,  the  speech  impulse  of  the  formed 
word  cannot  be  completed,  and  the  kinaesthetic  articu- 
latory centre  of  the  opposite  side  is  acted  upon  through 
commissural  fibres  in  just  the  same  way  as  the  articulatory 
centre  of  the  left  side  was  through  intercentral  fibres, 

r~~~^ 

in  the  beginning.  [TJ^-  process  of  education  is  very  slow 
and  must  be  given  artificial  aid  in  the  way  of  showing  the 
patient  what  movements  to  make  in  order  to  get  the  variety 
of  kinsesthesis  of  which  it  is  desired  to  store  up  memories.! 
The  utilization  of  this  suggestion  is  in  reality  at  the  bot- 
tom of  educating  patients  with  cortical  motor  aphasia  to 
speak. 

In  these  cases  in  which  it  is  desired  to  supply  the  articu- 
latory kinaesthetic  memories,  everything  is  to  be  gained  by 
the  use  of  the  physiological  alphabet,  educating  the  patient 
to  master  the  letter  sounds.  Even  the  briefest  considera- 
tion of  the  physiological  alphabet  would  require  more 
space  than  can  be  given,  and  I  prefer  to  say  nothing  in 
the  way  of  explanation  of  it  rather  than  give  a  faulty  and 
imperfect  exposition  of  the  subject.  To  those  who  would 
have  a  most  readable  article  on  the  subject,  the  first 
chapter  of  Wyllie's  "The  Disorders  of  Speech"  is  recom- 
mended. 

When  the  auditory  centre  is  diseased,  then  the  task 
is  to  get  a  primary  revival  of  the  idea  of  words  in  the 
visual  or  the  articulatory  centre.  This  is  a  very  much 
more  difficult  matter,  because  in  the  vast  majority  of 
peoples  the  primary  revival  takes  place  in  the  auditory 
centre,  and  when  this  is  destroyed  the  patient  is  stranded, 
from  a  speech  standpoint.  The  plan  of  education  is  in 


406  The  Facility  of  Speech. 

reality  that  which  is  used  for  deaf-mutes,  who  are  taught 
to  think  by  the  revival  of  the  word  impulse  by  the  visual 
centres,  the  revivification  of  visual  symbols  prompted  by 
hand  or  lip  movements.  In  case  of  those  born  deaf  and 
blind  the  primary  revival  is  in  the  articulatory  kinaesthetic 
centre,  which,  in  cases  like  that  of  Laura  Bridgman,  is  con- 
ditioned by  the  tactile  sense.  In  fact,  it  is  in  all  those 
defectives  who  learn  to  read  aloud  by  the  use  of  raised 
type.1 

Patients  with  the  auditory  form  of  sensory  aphasia 
should  be  patiently  taught  to  repeat  words  the  meaning  of 
which  is  conveyed  to  them  through  other  senses,  the 
visual,  tactual,  and  olfactory.  In  this  way  it  is  believed 
that  generally  the  auditory  area  of  the  same  side  that  is 
not  destroyed  or  of  the  opposite  side  may  develop  some 
executive  capacity. 

The  treatment  of  sensory  aphasia  conditioned  by  destruc- 
tion of  the  visual  centres  is  most  unsatisfactory,  and  very 
little  can  be  done  to  ameliorate  the  condition  of  such  pa- 
tients, even  though  all  modes  of  education  be  assiduously 
employed.  An  effort  should  be  made  to  teach  the  patient 
the  recognition  of  forgotten  symbols  in  connection  with 
the  arousal  of  other  memories  of  them,  the  auditory  and 
the  articulatory. 

In  short,  the  pedagogical  treatment  of  aphasia  embraces 
the  methods  of  the  kindergarten  and  the  methods  for  the 
instruction  of  those  defective  in  one  or  more  of  the  special 
senses.  Even  with  their  aid  but  little  can  be  done. 

1  I  am  aware  that  these  cases  are  somewhat  opposed  to  the  contention 
that  the  primary  revival  of  words  is  never  in  the  articulatory  centre,  and 
possibly  the  position  I  have  taken  may  have  to  be  modified  or  altered  by 
further  investigation: 


CHAPTER    XII. 

REMARKS  ON  THE  MEDICO-LEGAL  ASPECTS  OF 
APHASIA. 

APHASIA  is  so  frequently  a  symptom  of  mortal  disease, 
and  it  is  of  so  much  more  frequent  occurrence  in  the  aged 
than  in  the  young,  that  its  presence  and  occurrence  often 
give  rise  to  exigencies  necessitating  disposition  of  posses- 
sions in  such  a  way  as  to  satisfy  later  tribunals  of  justice. 
On  the  other  hand,  patients  with  aphasia  are  oftentimes  so 
changed  in  demeanor,  in  conduct,  and  in  appearance,  and 
they  respond  to  environmental  conditions  in  a  manner  so 
different  from  that  habitual  to  them  when  in  health,  that 
they  are  adjudged  insane  by  the  laity,  and,  unfortunately, 
occasionally  by  physicians  as  well.  These  two  facts  ne- 
cessitate a  discussion  of  the  testamentary  capacity  and  the 
mental  status  of  patients  with  aphasia. 

The  literature  bearing  on  the  testamentary  capacity  of 
aphasic  patients  is  not  very  extensive,  and,  by  way  of  intro- 
duction, it  may  be  said  that  much  of  it  is  valueless.  A 
quarter  of  a  century  back  the  subject  was  discussed  by 
Legrand  du  Saulle,1  by  Gallard/  by  Bateman3  and  others, 
but,  as  these  discussions  were  held  before  the  subcortical 

1  Gazette  des  Hopitaux,  June  and  July,  1868,  and  idem,  vol.  lv.,  1882. 
'-'  ( 'Unique  Medicale  de  la  Pitie,  reviewed  in  Le  Journal  de  Medecine  et  de 
Chirurgie  Pratiques,  vol.  xlviii.,  pp.  377-38°- 
cit. 


408  The  Faculty  of  Speecli. 

forms  of  sensory  and  motor  aphasia  were  separated  clini- 
cally and  established  on  a  firm  anatomical  basis,  they  are 
of  comparatively  slight  value.  For  example,  a  case  re- 
ported by  the  last-named  of  the  trio  mentioned  above : 
An  elderly  man,  about  to  be  married,  was  stricken  with 
right  hemiplegia  attended  with  aphasia.  He,  in  anticipa- 
tion of  death,  desired  to  make  a  will  for  the  benefit  of  his 
fiancee.  The  instrument  was  prepared  by  his  physician, 
with  whom  the  testator  communicated  by  means  of  signs 
which  the  former  understood.  The  testator  put  his  corrob- 
oration  on  communications  to  the  physician  by  making 
an  affirmative  or  negative  gesture  when  the  latter  repeated 
them  after  having  written  down  what  he  understood  the 
deponent  to  say.  For  instance,  he  held  up  the  hand  and 
extended  five  fingers  ;  then  closed  the  fingers  and  extended 
them  again ;  and  repeated  this  performance  three  times 
to  indicate  thirty.  On  being  interrogated  if  he  meant 
"  thousand"  he  nodded  affirmatively.  He  was  then  asked 
if  he  wished  }\\^>  fiancee  to  have  .£30,000 ;  he  again  nodded 
assent.  When  asked  if  it  was  his  wish  that  she  should  have 
this  sum  absolutely,  he  made  a  nod  of  negation.  When 
asked  if  she  was  to  have  it  during  her  life  and  then  to 
have  it  revert  to  his  own  family,  he  signified  assent.  He 
signed  the  document  by  making  his  mark,  but  owing  to  the 
non-satisfaction  of  a  technicality  of  the  law  the  will  was  not 
admitted  to  probate,  although  it  must  be  evident  to  every 
one  that  the  mental  faculties  of  the  patient  were  intact 
and  that  he  had  subcortical  motor  aphasia.  As  I  have 
already  hinted,  it  is  around  the  differentiation  of  the  sub- 
cortical  and  cortical  forms  of  aphasia  that  this  entire  ques- 
tion of  testamentary  capacity  revolves.  If  it  were  neces- 


Medico-Legal  Aspects  of  Aphasia.         409 

sary  to  define  the  status  of  the  aphasic  patient's  testamen- 
tary capacity  dogmatically  and  in  a  few  words,  I  should 
say  that,  although  every  case  is  a  law  unto  itself,  no  one  is 
of  sound  and  disposing  mind  who  has  true  aphasia — aphasia 
due  to  lesion  of  the  zone  of  language; — while  a  person 
who  has  any  form  of  subcortical  aphasia,  be  it  motor  or 
sensory,  may  be,  and  usually  is,  capable  of  indulging  in 
civil  transactions,  although  there  are  exceptions  to  the 
rule.  If  the  integrity  of  the  primary  speech  centres  con- 
stituting the  zone  of  language  is  necessary  for  the  full  and 
legitimate  genesis  and  notion  of  the  word,  then  disease  of 
any  of  them  must  be  attended  by  disorder  in  the  conception 
and  in  the  idea  of  the  word.  And  as  it  is  necessary  to 
employ  words  or  their  motor  equivalent  in  the  making  of  a 
will,  it  will  readily  be  seen  that  the  patient  with  true 
aphasia  cannot  do  this  in  a  way  to  satisfy  the  law.  Yet  a 
person  may  have  had  true  aphasia,  and  have  recovered 
sufficiently,  either  by  the  education  of  the  opposite  side  of 
the  brain,  or  by  the  assumption  of  function  by  unde- 
stroyed  portions  of  the  diseased  centre,  to  know  the  cor- 
rect application  of  words  and  to  use  them  rationally  and 
intellectually.  It  is  in  these  cases  that  the  observations 
of  the  physician  and  the  completeness  with  which  he  has 
examined  and  studied  the  case  should  have  the  greatest 
weight  in  deciding  as  to  the  patient's  testamentary 
capacity. 

Given  a  person  with  subcortical  aphasia,  the  matter  is 
very  different.  In  a  case  of  uncomplicated  subcortical 
motor  aphasia,  that  is,  not  associated  with  lesion  of  other 
parts  of  the  brain  that  might  interfere  with  intellectual 
functioning  of  the  brain,  the  individual  may  be  in  full- 


410  The  Faculty  of  Speech. 

est  possession  of  his  faculties,  including  internal  speech, 
and  have  simply  a  supreme  inability  to  externalize  his 
mental  content.  For  purpose  of  contrast  he  may  indeed 
be  compared  with  a  man  who  is  bound  and  gagged. 
Probably  no  one  would  contend  that  the  latter  is  incapa- 
ble of  making  a  will,  although  the  inability  to  do  so  with- 
out outside  aid  must  be  very  apparent.  The  testamentary 
capacity  of  patients  with  subcortical  motor  aphasia  may, 
however,  be  impaired  by  coincident  lesion  of  a  nature 
similar  to  that  causing  the  speech  defect,  occurring  in 
other  parts  of  the  brain.  For  instance,  a  thrombus  of  lue- 
tic  origin  located  subjacent  to  the  executive  motor  speech 
centre  may  cause  symptoms  of  subcortical  motor  aphasia, 
while  coincident  luetic  disease  of  the  blood-vessels  in 
other  parts  of  the  brain  may  cause  a  degree  of  dementia 
inconsistent  with  the  making  of  civil  contract.  But,  as 
I  have  said,  such  superadded  deficiencies  must  be  detected 
or  eliminated  by  the  examination  of  the  physician. 

Subcortical  sensory  aphasia,  be  it  of  the  auditory  or 
visual  kind,  offers  a  more  serious  obstacle  to  the  testa- 
mentary capacity  of  the  patient  than  does  the  subcortical 
motor  form,  because  in  the  former  the  indifferent  attitude 
and  the  inattentive  and  unnoticing  demeanor,  which  these 
patients  so  often  have,  lead  those  about  them,  and  others 
with  whom  they  may  come  in  contact,  to  look  upon  them 
as  insane.  The  testimony  of  these  of  the  laity  before  a 
Surrogate,  or  before  twelve  of  their  peers,  often  has  great 
influence  even  though  it  is  contradicted  by  testimony 
which  has  the  misfortune  to  be  called  "expert."  But  if 
the  aphasic  symptoms  be  wholly  of  a  subcortical  nature 
and  uncomplicated,  the  patient  has  no  defect  of  internal 


Medico-Legal  Aspects  of  Aphasia.         4 1  i 

speech,  and  because  of  the  shortcomings  of  internal  speech 
he  should  not  be  forced  into  the  category  of  those  of  un- 
sound mind  because  he  is  obliged  to  borrow  another's 
eyes  or  ears.  It  would  be  just  as  legitimate  to  contend 
that  a  highly  myopic  or  deaf  person  is  incapable  of  mak- 
ing a  will  because  he  cannot  lay  hands  on  his  glasses  or  his 
trumpet.  As  has  been  said  before,  the  analogy  is  over- 
drawn, because  uncomplicated  forms  of  subcortical  sensory 
aphasia  are  extremely  uncommon,  and  it  is  the  complica- 
tions or  coincident  symptoms  that  add  to  the  complexity 
of  the  question. 

Thus  it  will  be  seen  that  my  position  in  this  matter  is 
materially  different  from  that  of  many  writers  on  this 
subject.  For  instance,  I  cannot  agree  with  Cowers,  who 
says  :  "  Word  deafness  is  incompatible  with  will-making, 
because  it  is  impossible  to  know  whether  the  testator 
really  understands  what  is  said  to  him."  If  the  auditory 
pathways  were  the  only  ones  through  which  a  patient  could 
be  communicated  with,  this  would  be  true ;  but  word  deaf- 
ness may  be  complete  without  involvement  of  the  higher 
auditory  centre  and  with  the  central  visual  mechanism  in- 
tact, and  therefore  the  patient  can  be  communicated  with 
by  writing.  Even  in  a  case  of  word  deafness  and  word 
blindness  there  might  still  be  no  optic  aphasia  and  the  pa- 
tient could  be  communicated  with  by  pantomime,  sign 
language.  Neither  can  I  agree  with  Diller,1  who  says  by 
way  of  introduction  to  a  brief  discussion  on  the  medico- 
legal  aspects  of  aphasia :  "  In  such  a  study  neither  the  site 
of  the  lesion  nor  the  particular  division  or  subdivision  of 
aphasia  present  need  be  considered."  For  my  part,  I  be- 

1  Journal  of  Mental  and  Nervous  Disease,  May,  1894. 


412  The  Faculty  of  Speech. 

lieve  that  the  determination  of  the  variety  of  aphasia  that 
the  patient  has  is  the  most  important  thing  in  determin- 
ing the  patient's  capacity  to  make  contracts,  wills,  checks, 
and  indulge  in  other  civil  matters.  No  more  can  I  sub- 
scribe to  the  statement  that  "  Motor  aphasia  does  not  of 
necessity  incapacitate  the  patient  in  will-making,  etc.  "  If 
by  motor  aphasia  is  meant  aphasia  due  to  lesion  of  the  cen- 
tre in  which  are  stored  the  memories  of  articulation,  then 
such  aphasia  does  incapacitate  the  patient,  for  in  every 
case  of  this  kind  there  is  some  disturbance  of  internal 
speech,  not  to  speak  of  external  speech.  In  fact  the  ma- 
jority of  cases  that  have  become  famous  in  this  country 
on  account  of  the  litigation  connected  with  them,  in 
which  physicians  have  given  testimony  of  the  testamentary 
capacity  of  the  patient,  such  as  the  Beven  case,  analyzed 
by  Hughes;1  the  Parrish  case,  referred  to  by  Ray;2  and  a 
case  recorded  by  Clark,3  will  be  found  on  close  scrutiny  to 
be  cases  of  subcortical  aphasia,  and  it  was  because  of  the 
symptoms  of  the  latter  that  such  testimony  could  be  given, 
although  at  the  time  when  some  of  the  cases  occurred  the 
subcortical  forms  of  aphasia  had  not  been  separated. 

The  need  of  making  such  differentiation  in  every  case 
of  aphasia  when  it  is  necessary  to  determine  the  testa- 
mentary capacity,  or  to  make  a  determination  of  the 
mental  status  for  other  purpose,  is  well  illustrated  by  the 
pertinent  words  of  Hughlings  Jackson  on  the  subject: 
"  Such  a  question  as  '  Can  an'aphasic  make  a  will  ? '  cannot 
be  answered  any  more  than  the  question,  '  Will  a  piece  of 

1  American  Journal  of  Insanity,   January,  1879,  p.  410. 

3  "  Medical  Jurisprudence  of  Insanity." 

3  American  Journal  of  Insanity,  1892-93,  p.  291. 


Medico-Legal  Aspects  of  Aphasia.         4 1 3 

string  reach  across  this  room  ? '  The  question  should  be, 
can  this  or  that  person  make  a  will  ?"  And  the  determina- 
tion of  the  variety  of  aphasia  that  he  has  will  do  more  to 
answer  this  question  than  will  anything  else. 

Physicians  are  rarely  called  upon  to  decide  the  question 
of  the  responsibility  of  an  aphasic  in  criminal  processes ; 
but  when  they  are,  the  same  precepts  should  guide  them 
in  estimating  the  patient's  mental  responsibility  as  were 
laid  down  to  determine  his  testamentary  capacity.  It 
should  never  be  forgotten  that  the  majority  of  cases  of 
organic  aphasia  occur  with  diseases  of  the  brain  that  put 
great  inhibition  upon  the  unfortunate  victim's  passions  and 
emotions,  and  for  the  indulgence  and  manifestations  of 
these  he  should  not  be  held  responsible  in  the  same  way 
as  a  normal  man  is.  The  physicial  infirmities  of  patients 
with  aphasia  alone,  especially  the  motor  forms,  usually 
spare  them  from  crimes  against  person  and  State;  while 
the  speech  shortcomings  of  sensory  aphasia  are  of  such  a 
nature  that  patients  must  be  cared  for  by  others,  and  are 
therefore  kept  from  indulging  any  such  tendencies  that 
might  be  prompted.  Personally,  I  believe  that  a  patient 
with  subcortical  aphasia,  it  matters  not  of  what  form,  is 
as  capable  of  determining  between  right  and  wrong,  mctim 
and  tuum,  as  a  normal  person,  coincident  disease  of  the 
brain  that  might  impair  his  faculties  being  excluded. 
The  same  cannot  be  said  for  a  patient  who  has  lesion  of 
the  zone  of  language ;  but  in  cases  of  this  sort  the  even- 
tual determination  must  be  reached  from  personal  study  of 
the  case  and  not  from  its  conforming  to  any  hypothetical 
conditions. 


APPENDIX  I. 
CONDUCTION  APHASIA. 

IN  the  body  of  this  work  I  have  limited  myself  to  a  dis- 
cussion of  the  varieties  of  aphasia  that  have  been  substan- 
tiated by  morbid  anatomical  changes  found  post  mortem. 
No  one  doubts  the  reality  of  the  forms  of  aphasia  discussed 
in  the  text,  although  different  interpretations  have  been 
put  upon  the  symptomatic  accompaniments  of  each  of 
them  by  different  writers,  but  all  are  in  accord  as  to  their 
occurrence.  A  number  of  writers,  prompted  mainly  by 
theoretical  considerations,  have  described  several  varieties 
of  aphasia  dependent  upon  lesions  situated  between  the 
different  speech  centres.  To  these  varieties  they  have 
given  different  names,  according  to  the  posited  seat  of  the 
lesion.  The  most  plausible  of  these  subdivisions  is  one 
described  originally  by  Wernicke,  to  which  he  gave  the 
name  "  Leitungsaphasie,"  conduction  aphasia  (inter- 
central  aphasia,  connection  aphasia).1  Personally,  I  be- 
lieve that  theoretically  there  are  very  good  grounds  for 
the  differentiation  of  this  form  of  sensory  aphasia,  but  as 

1  Bramvvell  distinguishes  two  varieties  of  conduction  aphasia:  (i)  con- 
nection aphasia  due  to  interruption  of  the  connection  between  the  different 
cortical  speech  centres;  and  (2)  commissural  aphasia,  due  to  interruption  of 
the  commissural  connections  between  corresponding  speech  centres  in  the 
opposite  hemispheres.  He  remarks  that  in  the  present  state  of  our  knowl- 
edge it  is  impossible  to  distinguish  these  commissural  forms.  The  second 
distinction  seems  to  me  scarcely  warranted. 


Conduction  Aphasia.  415 

yet  there  is  no  convincing  anatomical  evidence  to  prove 
its  existence.  Therefore  it  is  referred  to  in  an  appendix, 
instead  of  in  the  body  of  the  work.  I  shall  cite  briefly, 
and  without  critical  comment,  some  cases  that  have  been 
contributed  to  establish  the  reality  of  this  form  of  aphasia. 
Even  the  most  casual  reader  of  the  chapter  "  Conception 
of  Aphasia"  will  recognize  that  the  explanation  of  the 
occurrence  of  the  one  symptom  of  conduction  aphasia, 
viz.,  paraphasia,  given  by  those  who  have  written  on  the 
subject  is  not  in  harmony  with  what  has  been  contended 
for  in  that  chapter.  The  cases  of  conduction  aphasia  that 
have  been  reported  can  all  be  explained  as  symptoms  of 
sensory  aphasia,  and  the  variations  in  the  clinical  picture 
depend  on  the  different  locations  of  the  lesion  in  the  zone 
of  language. 

Every  one  must  admit  the  possibility  of  the  existence 
of  a  lesion  in  the  zone  of  language  between  the  auditory 
centre  and  the  articulatory  kinaesthetic  centre,  without  de- 
struction of  either  of  these  centres.  On  the  other  hand, 
the  proximity  of  the  visual  and  auditory  centres  and  sub- 
jacency  of  the  radiations  of  Gratiolet  make  it  very  im- 
probable that  a  lesion  could  exist  between  these  two 
centres  and  not  implicate  either  of  them. 

A  number  of  the  most  reliable  writers  on  the  subject  of 
speech  disturbances  have  given  this  form  of  aphasia  ex- 
tensive consideration.  Wernicke,  Lichtheim,  Pick,  and 
other  writers  have  recorded  examples  in  support  of  its  oc- 
currence and  differentiation.  Personally  the  writer  is  of 
the  opinion  that  conduction  aphasia  can  rarely  be  differen- 
tiated from  sensory  aphasia,  of  which  it  is  a  part.  It  is 
possible  that  such  differentiation  may  be  made  when  the 


416  The  Facility  of  SpeecJi. 

lesion  is  of  the  island,  but  careful  observations  are  needed 
before  this  can  be  decided.  When  the  lesion  is  of  the 
island,  the  connection  between  the  auditory  centre  and 
Broca's  convolution  may  be  only  partially  interrupted  and 
some  impulses  sent  from  the  former  reach  the  latter.  All 
of  them  do  not.  This  remaining  partial  anatomical  con- 
nection has  been  taken  by  some  writers  (Ziehen)  to  explain 
the  occurrence  of  paraphasia  in  conduction  aphasia.  Be- 
fore reciting  the  symptomatology  that  has  been  attributed 
to  conduction  aphasia,  it  should  be  stated  that  if  the  artic- 
ulatory  centre  is  dependent  absolutely  upon  the  excitatory 
influence  of  the  auditory  centre,  as  so  many  physiologists 
believe  it  to  be,  then  an  intercentral  lesion  (a  Leitungs 
lesion  of  Wernicke)  should  produce  as  complete  inability 
to  speak  spontaneously  or  on  repetition  as  does  destruc- 
tion of  the  area  of  Broca  itself. 

In  the  conduction  aphasia  of  Wernicke  the  lesion  which 
is  posited  as  the  cause  of  the  aphasia  is  one  that  inter- 
rupts the  conducting  fibres  that  unite  the  centre  for  audi- 
tory and  articulatory  word  images.  Anatomically  such  a 
lesion  is  generally  in  the  floor  of  the  fissure  of  Sylvius  or 
in  the  island  of  Reil.  In  this  form  of  aphasia  the  speech 
centres  themselves  are  intact.  It  is  only  their  connections 
that  are  interfered  with.  Thus  neither  will  such  a  patient 
have  true  word  deafness  nor  will  there  be  inability  prop- 
erly to  speak  out  the  words ;  but,  as  the  connection  be- 
tween these  two  centres  is  interfered  with,  the  controlling 
influence  which  the  one,  the  auditory,  has  upon  the  other, 
the  articulatory  speech  centre,  will  be  lost,  and  therefore 
there  will  be  defect  in  the  proper  use  of  words.  Wernicke 
assumes  that  the  images  stored  in  Broca's  centre  are  re- 


Conduction  Aphasia. 

rived  directly  by  the  centre  in  which  primary  revival 
takes  place  from  the  object  representation.  The  speech 
disturbance  which  such  a  lesion  gives  rise  to  is  techni- 
cally known  as  paraphasia  and  occurs  in  repeating  as  well 
as  in  spontaneous  speaking.  Patients  with  this  form  of 
aphasia  understand  and  appreciate  everything  that  is  said 
to  them.  In  fact  they  are  responsive  to  all  forms  of  audi- 
tory stimulation,  and  such  auditory  stimulation  calls  up  in 
the  natural  way  the  proper  auditory  image  and  helps  to 
give  rise  to  the  proper  percept.  On  the  other  hand,  the 
patient  is  not  prevented  from  attempting  to  communicate 
his  ideas  and  thoughts,  and  the  thoughts  which  are  formed 
for  communication  are,  it  is  said,  the  correct  ones.  When, 
however,  he  endeavors  to  embody  these  in  words  the  pri- 
mary revival  of  the  auditory  centre  cannot  send  a  stimulus 
to  the  articulatory  centre,  because  the  conduction  is  inter- 
rupted. This  being  impossible,  the  motor  centre  en- 
deavors to  do  the  work  unguided  and  the  result  is  a  mis- 
use of  words.  The  patient  may  himself  be  cognizant  of 
the  shortcomings  in  his  speech  and  endeavor  to  correct 
them,  and  to  convey  his  meaning  by  pantomime.  These 
cases  are  very  rare,  and  when  they  occur  they  are  to  be 
diagnosed  principally  by  the  absence  of  symptoms  point- 
ing to  lesions  of  the  individual  speech  centres.  Occasion- 
ally paragraphia  has  been  noted  in  this  form  of  aphasic 
speech  disturbance.  When  the  latter  occurs,  the  explana- 
tion that  has  been  suggested  i-s  that  such  patients  have 
been  accustomed  in  writing  to  transcribe  the  word 
which  has  been  revived  primarily  by  the  articulatory 
centre  and  passed  on  by  the  auditory.  Thus  anything 
which  prevents  the  association  between  the  last  two 
27 


4i 8  The  Faculty  of  Speech. 

causes  disturbances  in  writing  analogous  to  those  of 
paraphasia. 

The  diagnosis  of  these  cases  is  led  up  to  more  by  the 
absence  than  by  the  presence  of  symptoms.  If  there  are 
paraphasia  and  absence  of  word  deafness,  and  nothing 
more,  the  diagnosis  of  conduction  aphasia  is  said  to  be 
justified. 

An  abstract  of  the  case  of  Lichtheim,  which  was  re- 
ported as  one  of  conduction  aphasia,  is  as  follows  : 

A  man,  forty-six  years  old,  with  incomplete  right-side 
hemiplegia.  No  history  could  be  obtained.  Examination 
showed  that  the  patient  understood  spoken,  written,  and 
printed  speech.  The  most  remarkable  feature  of  the  case 
was  paraphasia,  which  was  so  great  that  spoken  speech 
was  quite  unintelligible.  He  was  aware  of  the  mistakes 
in  his  production  and  tried  to  assist  himself  by  panto- 
mime. Writing  was  very  imperfect ;  he  disarranged  the 
order  of  the  letters  and  words,  and  it  was  difficult  to  get 
him  to  make  efforts  of  writing.  The  same  defects  were 
manifested  in  attempting  to  repeat  as  when  he  endeavored 
to  speak  voluntarily.  He  retained  the  ability  to  copy. 
The  autopsy  showed  extensive  lesions,  the  chief  one, 
according  to  the  writer,  being  of  the  island  and  of  the 
floor  of  the  Sylvian  fissure. 

The  extensiveness  of  the  lesion  robs  this  case  of  the 
weight  it  might  otherwise  have  in  contributing  to  a  sub- 
stantiation of  the  diagnosis  of  conduction  aphasia. 

The  following  is,  in  brief,  the  history  of  a  case  that  Pick 
has  recently  recorded  as  a  contribution  to  the  study  of 
insular  aphasia : 

A  woman,  Franciska  Dillkins,  sixty-six  years  old, 
had  suffered  from  infancy  with  epilepsy.  Otherwise  she 


Conduction   .  \phasia.  4 1 9 

had  been  well  until  her  sixty-fourth  year,  when  she  de- 
veloped symptoms  of  insanity;  spoke  falsely;  would  not 
.work ;  was  very  restless  at  night,  and  during  the  day  was 
absolutely  uncommunicative.  On  admission  to  the  hos- 
pital she  answered  the  general  questions  correctly,  in 
monosyllables,  but  often  made  use  of  the  same  answer. 
The  countenance  was  staring  and  unexpressive,  and  she 
made  the  impression  that  she  did  not  understand  questions 
and  commands  addressed  to  her.  After  being  taken  into 
the  hospital,  she  remained  most  of  the  time  in  bed,  and 
when  things  were  shown  to  her  she  took  no  notice  of  them 
or  held  them  unobservingly  in  the  hand.  At  other  times 
she  seemed  to  recognize  things  and  to  name  them  cor- 
rectly, i.e.,  objects  presented  to  the  visual  and  tactile  senses. 
Once  she  designated  money,  "  motarische  Sprache" 
(the  words  "  motorische  Sprache"  had  been  used  a  short 
time  before).  Physical  examination  showed  slight  pupil- 
lary inequality,  incomplete  right-side  hemiplegia  with- 
out facial  involvement,  increased  patellar  reflex,  but  no 
ankle  clonus. 

ILvamination. — What  is  your  name  ?  Franziska.  Your 
last  name?  Franziska.  Are  you  not  a  Dillkins?  Yes. 
How  old  are  you?  Answered  correctly  and  also  the  ques- 
tion as  to  her  last  residence,  where  she  had  lived  for  four 
years.  In  response  to  the  question  if  she  had  suffered  a 
stroke,  she  raised  the  right  arm  and  said  :  "  There  is  where 
the  stroke  affected  me."  In  response  to  the  question  if 
she  could  read  she  said  :  "  Formerly  I  could  read  but  not 
now."  Shown  some  money  and  asked  what  it  was,  she 
said:  "That  is  a  watch."  Is  it  not  money  ?  No.  Shown 
paper  money.  "That  is  two  gulden."  Shown  a  glass. 
"That  is  two  gulden."  Then  she  took  it  in  the  hand  and 
said  :  "  From  that  one  drinks  water."  What  is  it  called? 
"  From  that  one  drinks  water."  Shown  a  watch.  Looked 


420  The  Faculty  of  Speech. 

at  it  for  a  long  time  and  then  said  slowly :  "  I  do  not 
know  what  that  is."  When  the  name  was  said  in  her 
hearing,  she  said  :  "  Yes,  that  is  a  watch."  Shown  a  ring. 
That  is  a  watch."  For  what  purpose  is  it?  "  A  watch." 
Is  it  a  ring?  "Yes,  that  is  a  ring."  Although  she  was 
shown  the  ring  immediately  afterward  she  again  re- 
sponded "  That  is  a  watch.  Shown  a  knife.  "  That  is  a 
watch."  Then  she  took  it  in  her  hand  and  said  in  re- 
sponse to  the  repeated  question  :  "  Yes,  I  know  what  one 
does  with  that,"  but  she  gave  no  evidence  that  she  under- 
stood what  it  is  for.  A  burning  match.  "  That  is  ein 
Masche  (a  mesh?)."  She  did  not  concern  herself  when  it 
was  brought  close  to  her  face.  Afterward  she  made 
several  inarticulate  sounds  which  had  no  significance  for 
those  who  heard  them.  Ability  of  repetition  was 
markedly  impaired,  and  what  she  said  in  endeavoring  to 
repeat  could  not  be  understood.  Oftentimes  she  would 
harp  on  the  last  word  that  was  spoken. 

Tests  for  writing  and  reading  were  not  made,  as  she 
said  that  she  could  not  read  (formerly  she  could).  When 
requested  to  point  to  the  scissors,  she  pointed  to  a  key. 
Almost  all  of  the  objects  surrounding  her  she  called  "  A 
watch."  When  her  attention  was  called  to  pictures  on 
the  wall  she  called  them  "A  watch,"  but  apparently  was 
not  satisfied  and  said  "  Watches." 

Soon  after  this  she  was  seized  with  general  convulsions, 
which  began  with  conjugate  deviation  of  the  head  and 
eyes  toward  the  right.  The  pupils  were  widely  dilated  and 
reactionless.  Immediately  after  the  attack  there  was 
deviation  of  the  eyeballs  toward  the  left,  and  the  knee- 
jerks  were  not  elicitable.  Later  the  knee-jerks  were  ex- 
aggerated. After  the  convulsive  attacks  the  patient  was 
very  mute.  The  defectiveness  of  speech  became  more 
apparent.  The  hemiparesis  was  followed  by  profound 


Conduction  Aplictsia.  421 

hemicontracture.       After  another  convulsive  attack    she 
developed  an  extensive  bronchitis  and  soon  died. 

Autopsy.  —The  left  hemisphere  (opened  after  the 
method  of  Pitres)  showed  in  the  lenticular  nucleus,  ex- 
tending so  as  to  involve  the  claustrum  and  the  internal 
capsule,  an  old  focus  of  softening  of  the  size  of  a  walnut. 
The  micioscopical  examination  showed  that  the  entire 
island  in  its  total  transverse  diameter  was  interrupted  by 
the  focus. 

In  conclusion  Pick  remarks  that  he  does  not  offer  this 
as  a  pure  case  of  insular  aphasia,  because  of  the  fact 
there  were  other  changes,  including  a  universal  atrophy  of 
the  brain.  In  spite  of  this  he  says  the  case  may  be  cited 
as  a  "  negative  case,"  particularly  in  reference  to  the 
patient's  capacity  to  repeat.  These  cases  are  both  so  in- 
completely reported  clinically  and  anatomically  that  it  is 
unwise  to  attempt  criticism  of  them. 


APPENDIX    II. 
A  CASE  OF  ARTICULATORY-KIN^STHETIC  APHASIA. 

IN  the  text  only  as  many  cases  were  cited  as  was  thought 
absolutely  necessary  to  illustrate  different  types  of  aphasia. 
The  clinical  findings  in  the  patient  whose  case  I  am  about 
to  relate  mirror  so  completely,  however,  the  exact  conditions 
found  in  true  cortical  motor  aphasia,  articulatory-kinses- 
thetic  aphasia,  that  I  am  prompted  to  make  brief  note 
of  them  here.  Moreover,  I  believe  that  the  case  is  of  no 
small  importance  in  substantiating  the  claim  made  in  the 
text,  that  Broca's  convolution  sends  no  projection  fibres 
directly  to  the  internal  capsule  or  to  the  capsular  irradia- 
tion, and  that  it  is  in  reality  a  sensory  area. 

Mrs.  X ,  a  widow,  sixty-three  years  old,  the  mother 

of  eight  children,  has  had  a  vigorous,  active  life,  free  from 
ill  health,  save  that  twelve  years  ago  she  suffered  severely 
from  attacks  of  renal  calculi.  During  the  past  year  or  two 
she  has  complained  of  indigestion  and  more  recently  of  a 
dull,  aching  sensation  in  the  back  of  the  head  and  neck, 
with  occasional  attacks  of  very  severe  pain  in  the  left 
temple.  For  a  few  weeks  previous  to  the  beginning  of 
her  present  symptoms  she  suffered  from  insomnia,  from 
irritability,  nervousness,  and  forgetfulness.  Her  son,  a 
physician,  gives  the  following  account  of  the  onset  of  her 
aphasic  symptoms.  One  week  before  consulting  me  she 
discovered,  while  making  a  call,  that  her  speech  had  be- 


Articulatory-Khucsthctic  Aphasia.         423 

come,  without  warning,  very  much  embarrassed.  She 
could  not  finish  the  sentence  that  she  had  started  to  speak. 
She  forgot  what  she  wanted  to  say.  She  chafed  under 
this  impotence  and  got  very  much  excited.  She  returned 
home  in  a  street  car,  and  was  much  astonished  to  discover 
on  looking  at  the  signs  with  which  the  cars  are  lined 
that  she  was  quite  unable  to  comprehend  their  significa- 
tion. She  could  see  the  letters  and  words,  she  knew  that 
they  were  letters  and  words,  but  they  conveyed  no  mean- 
ing to  her.  When  she  got  home  she  tried  to  tell  her 
family  about  her  disability,  but  was  able  to  say  only  a  few 
words,  and  these  were  entirely  disconnected.  After  trying 
to  speak  for  a  time  she  became  excited  and  began  to  cry. 
On  the  following  day,  when  she  awakened,  she  could  say 
only  "  Yes"  or  "  No,"  but  as  the  day  wore  on  her  vocabulary 
became  somewhat  larger.  It  was  particularly  remarked 
that  when  she  was  excited  or  very  emotional  sometimes 
words  would  flow  out  of  her  mouth  in  an  astonishing 
manner.  From  that  time  until  I  saw  her  there  had  not 
been  very  much  change  in  her  capacity  for  speech  pro- 
duction. 

•  The  following  is  a  stenographic  report  of  the  exami- 
nation to  determine  disorder  of  voluntary  speech.  In 
response  to  the  question  to  tell  me  all  that  she  could 
concerning  the  onset  and  course  of  her  symptoms,  she 
said : 

"  Well,  mem-mem — three  weeks,  m-m-em — feel-m-em- 
em — sometimes  [prolonged  pause,  seems  to  be  thinking] 
couldn't  thought — no  thought — forget — but — eh — last  Fri- 
day [another  prolonged  pause]  am — no — noticed  they — I 
couldn't — eh — I — [prolonged  pause]  I  couldn't  tell,  am,  I 
don't,  I  can't,  can't  express  [explosively]  I  can't  tell — I 
cannot  [points  to  her  head  and  looks  weary].  It  seems,  I 
can't,  last  Monday,  con-con-nects — sentence,  two  or  three 


424  The  Faculty  of  Speech. 

words — gone.  Was — gone,  blank,  didn't  know.  Can't 
think,  was  gone,  forget — forget  everything.  Couldn't, 
couldn't,  can't." 

To  test  her  capacity  to  repeat,  I  asked  her  to  say  after 
me:  "I  stood  on  the  bridge  at  midnight."  Her  reply 
was  : 

"  I  stood — the — night,"  said  with  great  effort,  and  with 
apparent  endeavor  to  repeat  each  word  as  quickly  as  they 
fell  from  my  lips. 

"  Still  sits  the  schoolhouse  by  the  road  ?" 

"Forget — yes — the — the — s'  s'  s'  forget — road." 

"  Waterloo  was  a  battle  of  the  first  class,  won  by  a  cap- 
tain of  the  second." 

"  The  bat-tie,  ah,  me,  ah  me,  ah. " 

It  is  particularly  noticeable  that  when  I  speak  she  en- 
deavors to  say  the  words  after  me  very  rapidly  one  word 
after  another,  but  it  is  quite  imposible  for  her  to  repeat 
more  than  a  word  or  two.  The  patient  is  an  English  lady 
who  formerly  was  able  to  speak  German  very  fluently,  but 
when  I  recite  the  first  verse  of  Schiller's  "  Bell,"  begin- 
ning, "  Fest  gemauert  in  der  Erden,"  etc.,  she  is  not  able 
to  repeat  a  word  of  it.  I  then  ask  her  to  repeat  the  Lord's 
Prayer.  She  assures  me  by  nod  of  the  head  that  she  can- 
not do  so,  but  when  encouraged  to  try  she  says :  "  Fa' 

a'    ther— our    fa '    [gets    excited  and   I  believe  tries 

to  convey  to  me  that  she  was  unable  to  repeat  it  last 
evening].  I  then  ask  her  to  say  it  to  herself.  She  again 
indicates  that  it  is  entirely  impossible.  I  ask  her  if  it  is 
impossible,  and  she  says  "  Yes."  It  is  interesing  to  note 
that  when  I  encourage  her  to  say  it  to  herself  after  I  have 
told  her  that  I  am  going  to  say  it  in  my  internal  language 
to  determine  if  we  reach  the  end  simultaneously,  she 
adopts  the  conventional  attitude  and  manner,  probably 
thinking  that  they  will  prompt  the  recalcitrant  words,  but 


A  rticula tory-Kincestketic  Aphasia.         425 

all  to  no  purpose.  She  is  quite  unable  to  read,  either  in 
a  loud  voice  or  to  herself,  although  she  can  say  a  word  of 
what  she  reads  here  and  there,  but  words  and  sentences 
convey  no  meaning  to  her.  She  takes  up  the  newspaper, 
cons  it  carefully,  then  puts  it  down  with  an  expression  of 
dissatisfaction  and  disgust.  In  other  words,  there  are 
manifest  verbal  blindness  and  profound  alteration  of  men- 
tal images.  There  is  no  trace  of  hemianopsia. 

When  I  request  the  patient  to  write  her  name,  she  does 
so  promptly.  When  I  ask  her  to  write  the  name  of  her 
son,  she  does  so;  likewise  the  street  and  number  where 
she  resides.  She  is  absolutely  unable  to  write  spon- 
taneously. Her  capacity  to  write  from  dictation  Is 
tested  by  asking  her  to  write,  "  When  in  the  course 
of  human  events,"  but  she  is  absolutely  unable  to 
do  so.  The  only  word  that  is  produced  after  numer- 
ous attempts  and  repetitions  of  the  sentence  is  the  word 
"When." 

Writing  from  copy  is  done  without  trace  of  hesitation 
or  error;  and  when  she  is  asked  to  copy  printed  letters  in 
writing  she  does  so  with  great  readiness. 

She  comprehends  spoken  speech,  but  oftentimes  it  is 
necessary  to  repeat  before  the  meaning  of  what  is  said 
fully  dawns  upon  her.  In  other  words,  although  there  is 
no  word  deafness,  there  seems  to  be  some  difficulty  in 
calling  up  auditory  images  quickly  and  readily. 

She  has  no  trace  of  hemiplegia,  unless  we  call  a  slight 
asymmetry  of  the  angles  of  the  mouth  an  indication  of 
defective  cortical  innervation,  as  the  right  angle  of  the 
mouth  seems  to  be  a  trifle  lower  than  the  left.  There  is 
no  ataxia  or  inco-ordination  of  the  extremities ;  the  knee- 
jerks  are  lively  and  of  equal  intensity  on  both  sides;  the 
pupils  react  to  light  and  shadow ;  there  is  no  tone  deaf- 
ness or  object  blindness.  The  urine  contains  albumin 


426  The  Faculty  of  SpeecJi. 

and  casts ;  the  pulse  is  regular,  the  arteries  are  hard  and 
incompressible,  and  the  second  sound  of  the  heart  is  very 
much  accentuated.  In  other  words,  she  has  extensive 
arterio-capillary  fibrosis. 

The  interpretation  which  I  put  upon  the  case  is  as  fol- 
lows :  Pathological  diagnosis,  general  arterio-capillary 
fibrosis,  with  consequent  encephalomalacia  of  Broca's 
convolution.  Clinical  diagnosis,  true  cortical  motor 
aphasia,  articulatory-kinaesthetic  aphasia.  I  need  not  re- 
peat that  the  elicitable  symptoms  parallelize  in  every  de- 
tail those  which  have  been  proven  to  be  typical  of  this 
form  of  aphasia.  The  chief  deficiency  of  internal  lan- 
guage seems  to  be  an  inability  to  evoke  the  articulatory- 
kinjesthetic  images  of  the  word,  and  this  constitutes  a  gap 
in  the  circuit  of  internal-speech  impulses.  No  more  illus- 
trative case  could  be  cited  to  show  that  spontaneous  writ- 
ing and  writing  from  dictation  are  disordered  commensu- 
rately  with  voluntary  speech  in  this  form  of  aphasia. 
Moreover,  the  case  shows  with  uncommon  clearness  that 
a  striking  degree  of  verbal  blindness  occurs  with  cortical 
motor  aphasia.  It  is  probable  that  in  time  this  at  pres- 
ent manifest  verbal  blindness  will  become  latent,  and, 
if  the  pathological  process  on  which  the  symptoms  are 
dependent  does  not  progress,  that  a  future  careless  exami- 
nation might  fail  to  reveal  it. 

In  the  text  I  have  stated  that  hemiplegia  is  almost  con- 
stantly associated  with  cortical  motor  aphasia,  and  that  it 
is  dependent  upon  extension  of  the  lesion  to  the  Rolandic 
cortex.  This  case  is  an  exception  to  the  rule,  and  I  ven- 
ture to  believe  that  it  is  an  important  exception,  going  to 
demonstrate  that  Broca's  convolution  has  no  direct  repre- 


Articiitatory-Kin&stketic  Aphasia.        427 

sentation  in  the  capsular  irradiation,  and  finally  that  the 
products  of  its  activity  are  not  sent  directly  to  be  exter- 
nalized, but  are  sent  to  the  Rolandic  representation  of  the 
speech  musculature  and  to  the  area  of  representation  for 
other  modes  of  language  communication. 


NDEX. 


Abstract  thought,  development  of,  55 
Acoustic  sensations,  74 
Agraphia,  S 

early  explanation  of,  179 

localization  of,  26 
Amimia,  in  cortical  motor  aphasia, 

165 
Amnesia,  articulatory,  173 

verbal  is,  175 
Amusia,  259 

clinical  forms  of,  259 
Anatomy  of  the  brain,  remarks  on, 

86 

Aphasia,     articulatory    kinsesthetic, 
160 

as  a  localizing  symptom,  362 

associative  or  transcortical,    15 

classification  of,  9,  12 

conception  of,  86 

definition  of,  3,  6 

diagnosis  of,  324 

dynamic  forms  of,  353 

etioiogical  classification  of,  347 

etiology  of,  343 

history  of,  17 

medico-legal  aspects  of,  4°7 

morbid  anatomy  of,  370 

of  emission,  7 

of  reception,  S 

pathology  of, 

pedagogical  treatment  of,  406 

testamentary  capacity  in,  407 

treatment  of,  396 
Aphasic  patient,  education  of,  404 


Aphemia,  84 

Apperception,  definition  of,  10 

Apraxia,  293 

Articulate  speech,  dependency  on,  8 1 

during  sleep,  117 
Articulation,  mechanism  of,  78 
Articulatory  kimvsthetic  aphasia,  160 

a  case  of,  422 
Articulomoteur,  44 
Asemia,  2 

Association  centres  of  Flechsig,  107 
Association  fibres,  diagram  of,  101 
Association  pathways  of  the  brain, 

99 

Asymbolia.  2 
Asynergia  verbale,  21 
Asynergia  verbalis,  1 75 
Auditif.  44 
Auditory  aphasia,  244 

symptoms  of,  247 

variations  of  symptoms  in,  258 
Auditory  apparatus,  constitution  of, 

75 
Auditory  centre,  symptoms  of  lesion 

Of,   222 

Auditory  pathway,  development  of, 

5i 

Auditory  sphere. 
Autopsy,  conduct  of,  376 

Brain,  fissures  of,  88 

Broca,  dictum  of  and  hypothesis,  19 

original  contributions  of,  i  ~ 
Broca's  convolution    location  of,  91 


430 


Index. 


Ciphers,  acquisition  of  memory  for, 

277 

central  representation  of,  63 
Color,  perception  of,  73 
Concept  centre,  288 
Conduction  aphasia,  414 
Congenital  aphasia,  368 

adenoid  vegetations  in,  369 
Connection  aphasia,  414 
Cortical  and  subcortical  aphasia,  as- 
sociations of,  215 

differentiation  of,  214 
Cortical  motor  aphasia,  160 

disorder  of  writing  in,  176 

essential     accompaniments    of, 
164 

Diagnosis  of  aphasia,  324 
Dynamic  aphasia,  353 
Dyslexia,  278 

due  to  alcohol,  279 

in  motor  aphasia,  182 

occurrence  of,  132 

Epilepsy,    relation   of,    to    aphasia, 

354 

Etiology  of  aphasia,  343 
Expressive'  reactions,  40 

Fascicular  anarthria,  192 

Fissure  of  Sylvius,  kind  and  appear- 
ance of,  88 
relations  of,  90 

Flechsig's   method  of   dividing   the 
brain,  379 

Flechsig's  theories  of  localization,  102 

Fossa  of  Sylvius,  88 

Frontal  convolutions,  90 

Frontal  lobes,  functions  of,  46 

General  paresis,  aphasia  in,  368 
Graphic  motor  centre,  existence  of, 
136 


Hemianopsia,  homonymous,  in  vis- 
ual aphasia,  264 

Hemiplegia  and  cortical  motor  apha- 
sia, 426 

Hysteria,  relation  of,  to  aphasia,  356 

Infant,  cries  of,  50 

Inferior    pediculor-frontal    fascicle, 

102 
Intellectual  expression,  disorders  of, 

I 

Intercentral  aphasia,  414 
Internal  capsule,  constitution  of,  84 
reading,  disorder  of,  in  aphasia, 

131 
Island  of  Reil,  89 

Jargonaphasia,  23,  223 

Kinsesthetic  memories,  registration 
of,  116 

Laryngeal  muscles,  cortical  repre- 
sentation of,  125 

Larynx,  central  representation  of, 
1 20 

Light,  71 

Lips,  central  representation  of,  120 

Localization  of  speech  centre,  onto- 
genetic  importance  of,  128 

Logagraphia,  8 

Logaphasia,  8 

Medico-legal  aspects  of  aphasia,  407 

Memory  residua,  43 

Migraine,  relation  of,  to  aphasia,  353 

Mimic  reactions,  40 

Mind  blindness,  associated  with  word 

blindness,  392 

Morbid  anatomy  of  aphasia,  370 
Motor  aphasia,  emotional  language 

in,  171 
general  considerations,  153 


Index. 


Musical  deafness,  259 

Musical  memories,  allotment  of,  93 

Musical  sounds,  constitution  of    76 

Naming  centre,  288 

Nerve    fibres    of    the   hemispheres, 

myelination  of,  87 
Noises,  constitution  of,  76 

Object,  perception  of,  43 
Olfactory  sphere,  105 
Opercula,  divisions  of,  89. 
Optic  aphasia,  287 
Optic  nerve,  intracranial  course  of, 
94 

Palate,  central  representation  of,  120 
Pantomime,  genesis  of,  112,  114 
Paramnesia  verbale,  21 
Pathology  of  aphasia,  395 
Pedagogical    treatment   of   aphasia, 

400 

Percepts,  genesis  of,  57 
Physiological  alphabet,  405 
Projection   centres,  connections   of, 

1 06 

Propositionizing  centre,  289 
Proust-Lichtheim    test,    application 

of,  155 
Psychic  blindness  of  words,  286 

Respiratory  muscles,  cortical  repre- 
sentation of,  126 
Responsibility  of  aphasic   patients, 

413 

Revival  of  words,  site  of,  no 
Reynaud's  disease,  aphasia  in,  359 
Righthandedness,   determining 

causes  of   97 

relations  of,  to  speech  centres, 
95 

Seelenblindheit,  292 


Sensory  amimia,  283 

Sensory  amusia,  283 

Sensory  aphasia,  components  of,  295 
definition  of,  216 
disorder  of  reading  in,  249 
general  considerations,  216 
general  features  of,  2 1 9 
subdivision  of,  217 

Sensory  asymbolia,  283 

Sensory  pathways,  time  of  medulla- 
tion  of,  102 

SomEesthetic  area,  51,  103 

Speech,  analysis  of  the  genesis  and 
function  of,  40 

Speech  faculty,  unilateral  represen- 
tation of,  169 

Speech   mechanism,  constitution   of, 

54 

diagrams  of,  45,  47,  49 
Spelling,  psycho-genesis  of,  297 
Subcortical    aphasia,  distinction   of, 

from  cortical,  180 
Subcortical  motor  aphasia,  192 
location  of  lesion  of,  198 
symptoms  of,  194 
Subcortical  sensory  aphasia,  295 
Subcortical  visual  aphasia,  symptoms 

of,  295 
Subcortical  word  deafness,  lesion  of, 

393 
Syphilis  in  aphasia,  365 

Tactile  sphere,  103 

Temporal  convolutions,  enumera- 
tion of,  92 

Testamentary  capacity  in  aphasic 
patients,  407 

Tone  deafness,  259 

Tongue,  central  representation  of, 
120 

Total  aphasia,  313 

Toxic  aphasir.,  358 

Trr.nsitory  aphasia,  360 


43  2 


Index. 


Treatment  of  aphasia,  remarks  on, 
396 

Verbal  blindness,  261 
Verbal  deafness,  244 
Visual  aphasia,  261 

disorder  of  writing  in,  224 
Visual  area,  location  of,  263 
Visual  centre,  location  of,  93 
Visual  mechanism,  component  parts 

of,  70 

Visual  memories  for  form,  74 
Visual  sensation,  70 
Visual  sphere,  105 
Visuel,  44 

Word  blindness,  261 


Word  blindness,  first  use  of,  25 

intensity  of,  274 
Word  deafness,  244 

accompaniments  of,  248 

associations  of,  249 

first  use  of,  25 

Words  as  phonetic  phenomena,  84 
Writing,  development  of,  64 

loss  of  capacity  for,  in  sensory 
aphasia,  281 

Zone  of  language,  55,  no 
anatomical  basis  of,  94 
blood  supply  of,  218 
boundaries  and  blood  supply  of, 

343 
shape  of,  98 


IN1VERS// 


3   1158  00369  7355 


A     000354164    6 


